Public Record
Hallmark Manor
From CMS
Facility profile
- CMS overall rating
- 3 / 5
- Certified beds
- 147
- Avg. residents per day
- 99
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 110
- Inspections on file
- 9
- Last inspection
- 2025-05-13
*CMS
*CMS
*CMS
Citations
110 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0700Generalpotential for harm
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0761Generalpotential for harm
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.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0584Generalpotential for harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0007Generalpotential for harm
Address patient/client population and determine types of services needed.
- 0009Generalpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0342Generalpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0637Generalpotential for harm
Assess the resident when there is a significant change in condition
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0801Generalpotential for harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0773Generalpotential for harm
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0029Generalpotential for harm
Develop a communication plan.
- 0032Generalpotential for harm
Provide primary/alternate means for communication.
- 0034Generalpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0711Generalpotential for harm
Provide a written emergency evacuation plan.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0753Generalpotential for harm
Have restrictions on the use of highly flammable decorations.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0637Generalpotential for harm
Assess the resident when there is a significant change in condition
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0744Generalpotential for harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0761Generalpotential for harm
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.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0020Generalpotential for harm
Establish policies and procedures including evacuation.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0926Generalpotential for harm
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0729Generalpotential for harm
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0758Generalpotential for harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
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.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0888Generalpotential for harm
Ensure staff are vaccinated for COVID-19
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0020Generalpotential for harm
Establish policies and procedures including evacuation.
- 0032Generalpotential for harm
Provide primary/alternate means for communication.
- 0033Generalpotential for harm
Establish methods for sharing information.
- 0035Generalpotential for harm
Provide family notifications of emergency plan.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0037Generalpotential for harm
Establish staff and initial training requirements.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
FAQ
Questions and answers
- What is Hallmark Manor?
- Hallmark Manor is a Medicare- and Medicaid-certified nursing home in Federal Way, WA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 505313.
- What is the CMS rating for Hallmark Manor?
- Hallmark Manor has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Hallmark Manor have?
- Hallmark Manor is certified for 147 beds. It serves an average of 99 residents per day.
- How many citations does Hallmark Manor have?
- Hallmark Manor has 110 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Hallmark Manor last inspected?
- Hallmark Manor was last inspected on May 13, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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