HALLMARK MANOR (FEDERAL WAY, WA) Detailed Nursing Home Profile

Complaint Deficiency

Provide bedrooms that don't allow residents to see each other when privacy is needed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Restrictions on the use of flammable curtains
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Protected exits that allow the resident to escape the building
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Restrictions on the use of highly flammable materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Honor all of the resident's rights as a resident of the nursing home, free of coercion and reprisal, and as a citizen or resident of the United States
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Send and promptly deliver unopened mail to residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain comfortable sound levels
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Potential for minimal harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Determine if it is safe for the resident to self-administer drugs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide a safe, clean, comfortable and homelike environment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Potential for minimal harm
- Scope: Some
Train all employees on what to do in an emergency, and carry out announced staff drills
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Try to resolve each resident's complaints quickly
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed
- Harm: Potential for minimal harm
- Scope: Some
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Listen to the resident or family groups or act on their complaints or suggestions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give notice to the resident before a room or roommate change
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion unless it was unavoidable
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies and procedures for influenza and pneumococcal immunizations
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.870
Washington:	1.030

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.570
State:	0.679

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.440
Washington:	1.696

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.140
Washington:	0.132

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.140
State:	0.134

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	12.5%
State:	13.3%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	24.4%
State:	14.6%

Percent of long-stay high-risk residents with pressure ulcers

Here:	6.8%
State:	6.0%

Percent of long-stay residents who lose too much weight

Here:	12.6%
State:	7.5%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

Here:	84.6%
State:	52.9%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	7.6%
Washington:	4.7%

Percent of long-stay residents with a urinary tract infection

Here:	6.9%
State:	8.3%

Percent of long-stay residents who have depressive symptoms

Here:	2.4%
Washington:	13.2%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	1.1%
Washington:	3.0%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	97.7%
State:	95.1%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	96.6%
Washington:	95.7%

Percent of short-stay residents who self-report moderate to severe pain

Here:	54.8%
Washington:	27.2%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	0.6%
State:	1.5%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	99.3%
Washington:	89.4%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	96.4%
State:	87.7%

Percent of short-stay residents who newly received an antipsychotic medication

This Nursing Home:	1.3%
Washington:	2.1%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	15.0%
Washington:	22.9%

HALLMARK MANOR - FEDERAL WAY, WA

Complaint Deficiency

Staff Information

Quality Measures

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