FEDERAL WAY, Wash. — A year and a half ago, Annie Jenkins had mild dementia but could walk, take the bus independently, and remember her family. Today, she can't get out of bed without someone's help. Even when Annie has a minor medical issue, her family has to call professionals.
"She had been able to get around on her own and depending on herself to now completely dependent on someone else," said Elshadi Mengestie, Annie's niece.
In late 2023, Annie tripped and fell at home. Her sister, Gloria Powell and Elshadi placed her in Hallmark Manor in Federal Way to heal from ankle surgery.
"A 24-hour medical facility that specialized in physical therapy, wound care therapy, dementia care patients," said Gloria, describing what the facility advertised.
A Horrific Discovery
While at Hallmark Manor in spring of last year, legal documents say Annie's ankle bandages were discolored and giving off a putrid smell. When Gloria asked a nurse to change Annie's bandage, what she saw horrified her.
"When they took that bandage off, I just probably went into shock myself," Gloria said.
Legal documents say that despite the facility offering a "prompt examination of Annie's leg wound," she wasn't sent to the hospital until the next day — only after Gloria says she threatened to call 911.
When asked what happened to Annie’s ankle, Gloria said, "Well, it healed and then they let her get gangrene and they cut it off. They made her worse. They destroyed her life, the rest of her life that she had left."
In an email, Hallmark Manor said, “Residents are our No. 1 priority at Hallmark Manor. Their safety and well-being are the paramount goals in our day-to-day operations, and we have a dedicated staff of associates who are passionate about that mission of service. “
State Finds Facility at Fault
The state agrees Hallmark Manor failed Annie.
It investigated Gloria's neglect complaint and found the facility "failed to provide necessary treatment" and that this injury was "avoidable."
It wasn't an isolated incident. Federal Medicare data reveals that in the last year, Hallmark Manor racked up 23 citations — two and a half times the national average. Violations include "failing to provide dementia patients with appropriate treatment and services’ and failing to provide ‘care with dignity."
In a statement, Hallmark Manor said, “We take great pride in the services we provide our community, and our commitment to the safety of our residents and their families has never been higher. We will continue to provide quality and compassionate care to our residents as we focus on their overall health, well-being, and peace of mind.”
A Statewide Problem
Hallmark Manor's issues reflect a statewide problem.
Washington nursing homes receive nearly twice as many federal health and safety violations compared to facilities nationwide. In the last three years, 94% of the citations handed out in the state were for what they call low-level violations.
Toby Edelman with the nonprofit Center for Medicare Advocacy in Washington D.C. said that's a problem, that more important than the quantity of citations is the severity of them.
"I'd say that many of those deficiencies should be cited at considerably higher levels than they are and that there are much more serious problems than this no harm level would suggest," Edelman said. "Just having deficiencies is necessary but it's not sufficient. We need to have some consequence for not complying with the law."
State Response and Penalties
The state said it doesn't have an answer as to why more deficiencies are found in Washington nursing homes or why the ones that are handed out are mostly for low-level violations.
"We may have higher citations than other states, but we're really just focused on the work that we do here and how we're trying to conduct it," said Miriam Mina, a state official with DSHS.
After all that happened to Annie and her family, the state handed out what the family says was inadequate. Hallmark Manor received a citation requiring them to submit a plan of correction and pay a fine of $1,000.
“Because they're a company or a business, it just seems like, OK, we'll give you a slap on the wrist and a pass. How many passes have they gotten? Because obviously this isn't the first one,” said Elshadi.
Mina said she believes the state is holding nursing homes accountable.
"Nursing homes are being held accountable," she said. "That is part of our role to ensure that they are in compliance with following federal and state regulations.”
Calls for Accountability
Attorney Nick Andrews represents Annie and her family in a lawsuit filed late last year against Hallmark Manor. He said what happened to Annie was criminal and there needs to be more accountability.
"What's terrifying for the community should be all the individuals that are in these types of facilities that don't have advocates or voices. That's terrifying and it should be," Andrews said. "Hopefully with this lawsuit, we can effectuate some change so there is accountability because it's not coming from the state at this point that we can see."
"I think they should all go to jail. To be honest, I think someone needs to answer for this. Someone needs to be prosecuted for this," said Gloria.
Hallmark Manor said in a statement, “We are aware of a lawsuit filed against our facility by the family of a former resident who received care at our facility. Due to the pending legal action, as well as HIPAA, we cannot provide specific information on the resident or the resident’s time at our facility."