Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Hallmar Village during CMS and state inspections, most recent first.
Surveyors found that staff did not respond to call lights within the Administrator’s 15‑minute expectation for two residents who required staff assistance with ADLs and had histories of falls. One resident with intact cognition, dementia, heart failure, diabetes, and bowel issues had a care plan intervention for timely call light response, yet electronic records showed a call light left unanswered for over 24 minutes, and the resident reported that call lights were not always answered promptly. Another resident with moderately impaired cognition, total dependence for toileting and dressing, and a left humerus fracture had multiple call light activations documented as unanswered for more than 25 minutes, despite a care plan and facility policy requiring prompt response and staff awareness of all call lights.
Food items were left undated or expired in kitchen refrigerators, and scoops were left inside sugar containers in the main kitchen. The facility also had incomplete food temperature, dishwasher temperature, and refrigerator/freezer logs, and a cook served minced and moist meals to 2 residents without checking food temperatures before service.
A facility failed to provide enough nursing staff to meet resident needs in a timely manner, with repeated reports of call lights going unanswered for 20 to 45 minutes and staff turning lights off without completing care. Resident council minutes, a device activity report, and interviews with residents, a family member, a CNA, and the DON documented ongoing delays, including a resident waiting for transfer help and another left on a bedpan, while the DON acknowledged a history of call light issues and an expectation that lights be answered within 15 minutes.
A resident with dementia, malnutrition, neuropathy, and severe mobility dependence did not receive consistent ROM services despite documentation for active ROM and a maintenance program. Observation showed the resident protecting his left side and not moving the left shoulder, elbow, or wrist, while EHR documentation showed ROM was offered only once in the prior 30 days. The restorative aide said she had not gotten to the resident lately and did not report refusals, and the DON confirmed the resident should have been receiving ROM services.
Failure to follow an NPO order and approved menu substitutions. A resident with dementia, dysphagia, malnutrition, and g-tube status was supposed to be NPO but was given a meal tray and had prior incidents of being fed by mistake. In addition, during a meal observation, a resident on a pureed diet received items not listed on the posted menu, and the dietary manager could not produce a dietitian-approved substitution form.
A resident with neurogenic bladder, dementia, anxiety, chronic pain, and a suprapubic catheter was left on a bed pan for hours on more than one occasion, and her call light was not always within reach. The POA reported the resident had been on the bed pan since 2:00 PM, and staff documentation showed CNAs failed to give report, leaving the oncoming CNA unaware she was on the bed pan. The nurse noted a red ring on the buttock consistent with prolonged bed pan use, and the DON acknowledged a history of bed pan concerns.
Unlabeled insulin and an unlocked med cart were observed during insulin administration for a resident with Type 2 DM. In a separate event, a TMA handed a Trazodone tablet to a family member for self-administration to a resident with moderate cognitive impairment, rather than administering it directly and verifying the dose was taken.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Several residents reported being treated roughly and without dignity by a CNA, including being handled harshly during transfers and personal care, ignored when requesting assistance, and witnessing staff using cell phones and earbuds during care. Staff interviews confirmed the CNA's rude behavior and inappropriate handling of residents, including performing a two-person lift alone.
Staff failed to consistently use required gowns and gloves during high-contact care activities for three residents with wounds and indwelling devices. In multiple instances, staff performed wound care and catheter care wearing only gloves, despite care plans and posted signage directing the use of both gowns and gloves. Supplies were available in resident rooms, but staff did not adhere to the facility's Enhanced Barrier Precautions policy.
A resident with moderate cognitive impairment fell and was injured after her walker was left out of reach, and she was not checked on for several hours during a night shift. The CNA responsible was found sleeping and failed to conduct required safety rounds, leaving multiple residents without call lights in reach. The facility's call light policy was not followed, contributing to the incident.
The facility failed to treat residents with dignity and respect, as evidenced by multiple observations and interviews. A resident with moderate cognitive impairment was denied assistance by staff despite her requests, leading to frustration and feelings of neglect. Another resident reported issues with receiving showers at her preferred time, feeling that her reasonable requests were not accommodated. Resident council meetings highlighted ongoing issues, including staff not introducing themselves, ignoring requests for assistance, and discussing private matters in public settings.
The facility failed to provide consistent bathing for two residents, leading to a deficiency in care. One resident, with intact cognition, expressed dissatisfaction with the timing of her showers, which were often delayed. Another resident, fully dependent on staff, experienced inconsistencies in receiving scheduled baths. The Clinical Administrator was unaware of these issues, despite complaints in resident council meetings.
The facility failed to maintain accurate medical records and transcribe orders correctly for two residents. One resident did not have documentation for Lorazepam administration, while another did not receive Carbidopa-Levodopa due to transcription errors. These deficiencies led to lapses in care, with one resident experiencing worsened Parkinson's symptoms. The facility's record-keeping and order transcription processes were inadequate.
A resident with intact cognitive ability and independence in mobility left the unit without staff knowledge on two occasions, despite a care plan requiring communication with staff before leaving. The facility's policy mandates a sign-in/sign-out log, but the resident's departures were not documented, indicating a lapse in monitoring procedures.
A facility failed to promptly address a bedbug infestation, affecting two residents with severe cognitive impairments. One resident developed scratches and another had itchy blisters due to delayed pest control treatments. The facility's pest control policy was not effectively implemented, resulting in discomfort for the residents.
A resident with vascular dementia and psychoactive substance abuse attempted to leave the facility unaccompanied, triggering a door alarm. Despite being independent with ambulation, the resident had intermittent confusion and a desire to go home. The Care Plan was not updated promptly to address the elopement risk, as acknowledged by the DON during an interview.
A resident with multiple health conditions experienced severe pain and bleeding due to improper catheter insertion by an RN, leading to hospitalization. Despite using sterile technique, the catheter was not correctly placed, causing significant trauma and blood loss. The resident required hospital intervention for acute gross hematuria and potential clot formation.
The facility did not comply with professional standards for food service safety. Observations revealed multiple food items in the prep area's fridge, walk-in cooler, walk-in freezer, and dry storage area were open, undated, and unlabeled. The Dietary Manager confirmed these findings, which violated the facility's policy requiring proper labeling and dating of ready-to-eat and potentially hazardous foods.
A resident did not receive their Parkinson's medication, Carbidopa-Levodopa, at the prescribed times. The medication was scheduled to be given five times daily, but on one occasion, the 2 p.m. dose was administered late, and the 6 p.m. dose was given shortly after, violating the facility's policy for timely medication administration.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights within the Administrator’s stated expectation of 15 minutes, despite care plan directives and facility policy requiring prompt responses. For Resident #1, who had dementia with agitation, heart failure, diabetes mellitus, intact cognition (BIMS 15/15), and required assistance with ADLs due to weakness and impaired mobility, the care plan included an intervention to answer the call light timely because of a history of falls. Electronic call light records showed that on 10/24/25 at 6:36 p.m., the resident’s call light remained unanswered for 24 minutes and 32 seconds. In an interview, this resident reported that call lights were not always answered timely and stated she had bowel problems and needed to get to the toilet fairly quickly. Resident #2 had moderately impaired cognition (BIMS 10/15), did not ambulate, and was totally dependent on staff for toileting hygiene, dressing, and bathing, with diagnoses including a left humerus fracture and a history of falls. The resident’s care plan directed staff to place the call light within reach and to answer it promptly. Electronic call light records showed multiple instances where this resident’s call light remained on for more than 25 minutes: on 1/28/26 at 5:51 p.m. for 26 minutes and 42 seconds, on 1/28/26 at 6:49 p.m. for 25 minutes and 55 seconds, and on 1/29/26 at 12:57 p.m. for 26 minutes and 8 seconds. The facility’s Call Light Policy, dated November 2022, required all staff to be aware of and promptly answer call lights, regardless of assignment, and the Administrator confirmed her expectation that call lights be answered within 15 minutes of activation.
Food Storage, Temperature Monitoring, and Sanitation Deficiencies
Penalty
Summary
Food items were not properly discarded or stored in 2 of 3 kitchens. During an initial walkthrough of serving kitchen #2, a container of cut fruit covered with plastic cling and an opened bag of whipped cream were observed in the refrigerator without dates. In the main kitchen, 4 plastic containers of coleslaw dated 9/25/25 were observed in a refrigerator near the serving area, and 2 large containers of white sugar and brown sugar each had a scoop left inside the bin. The Dietary Manager stated that stored food items must be labeled with an opened date or date prepared, that the coleslaw should have been discarded on 9/28/25, and that staff know not to keep scoops in containers. The facility also failed to maintain required temperature and sanitation logs and failed to check mechanically altered diet temperatures before service. Review of kitchen records showed missing food temperature checks for 24 meals, a largely blank high-temperature dishwasher log in the main kitchen, missing dishwasher temperature checks in serving kitchens #1 and #2, and incomplete refrigerator/freezer temperature logs in the main kitchen and serving kitchens #1 and #2. During noon meal service in serving kitchen #1, a cook served minced and moist tuna casserole and minced and moist broccoli to 2 residents without checking the food temperature, stating the food was steaming when removed from the warming storage unit. The facility was unable to provide policies for food storage, food temperatures, dishwasher temperatures, refrigerator/freezer temperatures, or kitchen sanitation.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs in a timely manner and did not ensure a licensed nurse was in charge on each shift as reflected by repeated delays in answering call lights. Residents reported waiting 20 to 45 minutes for call lights to be answered, and some stated staff turned off the call light without completing the requested care. A Quality Concern Form documented one resident waited 20 minutes for a second CNA to assist with a transfer, and resident council minutes repeatedly noted that call lights were still not being answered promptly. Resident council minutes from multiple meetings documented ongoing complaints that aides were shutting off call lights without assisting residents, with reports of waits of 20 to 30 minutes and one resident stating a call light was on for 30 minutes. A Device Activity Report showed 33 instances on the second floor where call lights remained active between 16 minutes 4 seconds and 41 minutes 45 seconds. During interviews, a family member reported a call light was turned off and the aide left without providing care, resulting in a 40-minute wait, and another resident reported waiting about a half hour after pulling the cord. The DON acknowledged an expectation that call lights be answered within 15 minutes and confirmed there was a history of call light issues.
Failure to Provide Ordered ROM Services
Penalty
Summary
The facility failed to ensure a resident with limited ROM received appropriate treatment and services. The resident had diagnoses including non-Alzheimer's dementia, malnutrition, and idiopathic peripheral autonomic neuropathy, and the MDS documented that he was dependent on staff for transfers, hygiene, and bed mobility and used a wheelchair. The care plan identified impaired mobility, generalized weakness, impaired cognition, and end-of-life stage, but it did not address active or passive ROM. A later care plan intervention directed staff to assess functional ability with bed mobility, transfers, walking, and locomotion, but ROM was still not included. During observation, the resident was seated in a high-back wheelchair with his feet on the pedals and appeared protective of his left side, not moving his left shoulder, elbow, or wrist. The EHR task tab showed an active ROM program for bilateral upper and lower extremities or use of a recumbent exercise machine, but completion documentation showed the resident was offered ROM only once in the prior 30 days, with all other entries marked not applicable. A maintenance program dated earlier directed staff to assist with bilateral active ROM using a 3-pound dowel, but the facility later stated the resident needed a new maintenance program assessment and that ROM was addressed with restorative therapy. The restorative aide stated she should be doing ROM exercises but had not gotten to the resident lately, and she did not report refusals to anyone. The DON stated the resident should be getting ROM from the restorative aide and that all residents needing it should receive ROM services, but the facility did not provide a policy or procedure related to ROM services.
Failure to Follow NPO Diet Orders and Approved Menu Substitutions
Penalty
Summary
The facility failed to ensure a resident with an NPO order was kept free from oral food intake when a meal tray was delivered to the resident's room. Resident #4 had diagnoses including non-Alzheimer's dementia, malnutrition, dysphagia, and gastrostomy status, and the MDS showed the resident had a feeding tube and received 51% or more of total calories through tube feeding. The care plan identified that the resident required tube feeding due to dysphagia, was NPO, and may occasionally try to find snacks and eat by mouth. Facility documentation showed prior incidents in which the resident was mistakenly given scrambled eggs and later was found with a tray containing empty plates and utensils after reportedly eating a sandwich for supper. A resident occurrence report stated the resident was given food despite being NPO, and the cause was identified as confusion between two residents with the same first name and an agency CNA erroneously giving the meal tray to Resident #4. The facility also failed to ensure residents on a pureed diet received foods listed on the menu or dietitian-approved substitutions. During noon meal observation, a cook plated pureed meals for two residents, including one resident who received pureed chicken, corn, rice, and chocolate pudding. The posted menu for that meal listed chicken gumbo soup, tuna casserole, broccoli, and cheesecake, with alternative items of ginger chicken thigh and fried rice. The dietitian and dietary manager stated that a substitution form was required when serving foods not on the approved menu so the dietitian could sign off, but the dietary manager could not locate a substitution form for the pureed corn used instead of broccoli. The facility also lacked policy or procedures for NPO diets or menu item substitutions.
Failure to Provide Dignified Toileting Care
Penalty
Summary
The facility failed to ensure dignified care for Resident #31, who had diagnoses including neurogenic bladder, non-Alzheimer's dementia, anxiety, chronic pain, and neurogenic bowel with a suprapubic catheter. The resident's care plan directed staff to assess bowel and bladder function and follow facility protocol for bowel issues. During interviews, the resident and her spouse reported that she had been left on a bed pan for hours on at least two occasions and that her call light had been out of reach during one of the incidents. The resident stated she was afraid when she felt alone. A progress note documented that the resident's POA reported she had been on the bed pan since 2:00 PM when he left, and another note stated the CNAs did not give each other report at 2:00 PM and the oncoming CNA did not know the resident had been placed on the bed pan. The nurse found the resident's skin intact but noted a red ring around her buttock consistent with sitting on a bed pan. Staff interviews confirmed the resident frequently complained when placed on the bed pan, and the DON acknowledged a history of bed pan concerns and that there had been concern about staff using phone timers instead of the door timer, which the resident's spouse had noticed.
Unlabeled insulin and unsecured medication cart; medication given to family member for administration
Penalty
Summary
Insulin used for a resident with Type 2 DM was not properly labeled and was stored unsecured during administration. Resident #4 had an active order for Novolog insulin injections with meals, and during an observation the RN prepared the insulin pen at the treatment cart. The pen did not have an opened date or expiration date identified on the label, and the RN stated the date sticker had been left blank and did not know when the insulin had been opened or expired. The same observation showed the treatment cart containing insulins and medicated creams was left unlocked when the RN walked away from it to enter the resident’s room. The RN stated medication and treatment carts must be locked when staff leave the cart. The DON also stated the expectation was for treatment carts to be locked when not in use to ensure safe storage of resident insulins and medicated treatments. Medication was also handled in a way that did not keep administration with authorized staff. Resident #5 had moderate cognitive impairment and diagnoses including osteoarthritis, anxiety disorder, and depression, with a care plan calling for staff assistance with medications as needed. A family member reported that a Trazodone tablet was handed to her by a TMA at the medication cart so she could take it to the resident and administer it herself in the resident’s room, and the facility grievance record documented the same event. The employee file for the TMA reflected that the medication was handed to the family member and that the staff member could not verify the resident took the medication.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
Multiple residents experienced a lack of respect and dignity in their care, as evidenced by interviews and clinical record reviews. One resident, with fluctuating cognitive status, reported that a CNA assisted her in a harsh and rough manner, both in the dining room and in her own room, including being jerked up from a seated position without warning. The resident also stated that the CNA was demanding, not gentle during showers, and dismissive when bathroom assistance was requested. Despite reporting these concerns to the administrator, the resident did not observe any improvement in the CNA's behavior. Another resident, cognitively intact, expressed that staff did not treat her or others with dignity. She described being awakened during the night for skin audits and wound treatments, and reported that staff would answer her call light but not return to provide the needed assistance. The resident also observed staff using cell phones and listening to music with earbuds while providing care. She recounted an incident where a CNA refused to assist another staff member with her transfer, and after reporting a near fall, the CNA confronted her, called her a liar, and threatened to write her up. Following this, the resident felt the CNA intentionally ignored her call lights. A third resident, also cognitively intact and requiring extensive assistance for transfers, reported being treated roughly and like a "rag doll" by a CNA, which caused her to fear injury. The resident stated the CNA showed little interest in helping and was rough when dressing her. Staff interviews corroborated these accounts, noting the CNA's rude behavior towards both residents and staff, and confirming that the CNA performed a two-person lift alone. The facility's own investigation documented multiple residents reporting rough care and inappropriate handling by the CNA.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) and standard precautions to prevent the spread of infections for three residents with wounds and/or indwelling medical devices. For one resident with a recent surgical procedure and a groin incision, a registered nurse performed wound care without donning a gown, despite signage and care plan instructions requiring both gloves and a gown for such procedures. The nurse stated she considered wearing a gown but decided against it because the wound was not open. Another resident with diabetes, heart disease, wounds, and an indwelling Foley catheter required total assistance for transfers and had a care plan directing staff to use EBP, including gown and gloves, during high-contact care activities. A certified nursing assistant emptied the resident's catheter bag wearing only gloves, failing to use a gown as required by the care plan and posted signage. The staff member later acknowledged awareness of the EBP signage but did not follow the protocol. A third resident with cognitive abilities, a stage three inter-gluteal pressure ulcer, and an indwelling urinary catheter required extensive assistance and use of a mechanical lift. During care involving transfer, incontinence care, and wound cleansing, three staff members wore gloves but did not don gowns, contrary to the care plan and facility policy. Additionally, wash cloths used for wound care were placed directly on the bed sheet without a barrier, and a graduated cylinder used for emptying the Foley bag was placed on the bed frame without a barrier. The facility's policy clearly required gowns and gloves for high-contact care activities involving wounds and indwelling devices.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for residents, particularly affecting a resident with moderate cognitive impairment who was left without her walker within reach, leading to a fall and injury. The resident, who was independent in her room with her walker, was found on the floor with a head wound after attempting to reach her walker, which had been placed out of reach. The incident occurred during a night shift when the resident was not checked on for a significant amount of time, resulting in her lying on the floor for several hours before being discovered by staff. The night shift staff, including an LPN and a CNA, failed to perform safety rounds as required. The CNA responsible for the resident's care was found sleeping during the shift and did not conduct the necessary rounds or respond to call lights promptly. This negligence left several residents without call lights in reach and others with unanswered call lights, further compromising their safety and care. The CNA had previously been coached on the importance of rounding and maintaining resident room order, but these protocols were not followed during the shift in question. The facility's call light policy, which mandates prompt response to call lights and regular safety checks, was not adhered to, contributing to the resident's fall and subsequent injury. The failure to conduct rounds and ensure residents' needs were met resulted in the resident being left in a vulnerable position for an extended period. The incident highlights a breakdown in staff responsibilities and adherence to established care protocols, leading to harm to the resident.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by multiple observations and interviews. Resident #3, who has moderate cognitive impairment, was observed being denied assistance by staff despite her requests. An occupational therapist instructed staff not to assist the resident with tasks such as applying chapstick, asserting that the resident was independent. However, Resident #3 expressed frustration when she was left in soiled briefs and was denied timely assistance, which she reported to management. Additionally, she mentioned missing baths due to staff not returning with necessary supplies. Resident #4, who has intact cognition, reported issues with receiving showers at her preferred time. She expressed dissatisfaction with staff delaying her shower until after she was dressed, despite her request for an early morning shower. She felt that her request was reasonable and should be accommodated, but staff often cited being too busy with other residents. This issue was also raised in resident council meetings, where residents voiced concerns about staff not respecting their preferences and needs. The resident council meeting notes highlighted several ongoing issues, including staff not introducing themselves, ignoring residents' requests for assistance, and discussing private matters in public settings. Residents reported feeling disrespected and neglected, with staff failing to respond promptly to call lights and leaving soiled linens in rooms. The facility's policy on resident rights emphasizes person-centered care and collaboration with residents, but the reported incidents indicate a failure to uphold these standards.
Inconsistent Bathing Schedules for Residents
Penalty
Summary
The facility failed to provide consistent bathing for two residents, leading to a deficiency in care. Resident #4, who has intact cognition and requires substantial assistance for bathing, expressed dissatisfaction with the timing of her showers. She prefers to bathe once a week on Saturdays at 6:45 am, but staff often delay her shower until after she is dressed, citing busyness and other residents' needs. Over the past month, Resident #4 received baths at times inconsistent with her preference, and on one occasion, bathing was marked as refused. Resident #7, who is fully dependent on staff for bathing, also experienced inconsistencies in receiving scheduled baths. The records show that he received baths on only a few occasions, with several instances marked as not applicable. The Clinical Administrator was unaware of these issues and acknowledged the need for better accountability, as complaints about bathing schedules were a recurring topic in resident council meetings.
Deficiencies in Medical Record-Keeping and Order Transcription
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in their care. For Resident #6, the facility did not document the administration of Lorazepam, an anti-anxiety medication, despite having an order for it. The medication was never used, and the facility could not locate the complete Controlled Drug Receipt/Record/Disposition form, which should have documented the medication's receipt and destruction. The Clinical Administrator confirmed that the medication was delivered and later destroyed, but the lack of documentation indicates a failure in record-keeping. For Resident #7, the facility inaccurately transcribed medical orders, resulting in the resident not receiving Carbidopa-Levodopa, a medication for Parkinson's Disease, for a period of time. The ARNP had ordered the continuation of the medication, but the facility's records incorrectly showed it was discontinued. This error was discovered when the resident's family provided a copy of the correct order. The resident experienced worsened Parkinson's symptoms during the time the medication was not administered. The Clinical Administrator acknowledged the error and noted that the staff member responsible for the transcription had prior performance issues. The facility's record retention policy requires that all records comply with federal and state regulations, but the deficiencies in documentation for both residents indicate a failure to adhere to these standards. The lack of proper documentation and transcription of medical orders led to significant lapses in the care provided to the residents, highlighting issues in the facility's record-keeping and order transcription processes.
Failure to Monitor Resident Leaving Unit
Penalty
Summary
The facility failed to implement an effective process to monitor a resident who left their unit without staff knowledge on two occasions. The resident, who had diagnoses including poly substance abuse, vascular dementia, and acute kidney failure, was noted to have intact cognitive ability and independence in ambulation, transfers, and dressing. Despite a care plan update on 9/26/24, which required the resident to communicate with staff before leaving the unit and for staff to place a reminder sign on the exit door, the resident left the unit without signing out on 10/18/24 and 10/19/24. The facility's Wandering and Elopement Policy, modified in December 2022, mandates a sign-in/sign-out log for residents leaving the unit. However, the sign-in/sign-out sheet for the relevant period did not include the resident's name, indicating a failure to document the resident's departures. During an interview, the Director of Nurses acknowledged the expectation for the resident to sign out, highlighting a lapse in adherence to the policy and care plan interventions.
Delayed Pest Control Response Leads to Resident Discomfort
Penalty
Summary
The facility failed to maintain an effective pest control policy, resulting in a bedbug infestation affecting multiple residents. Resident #5, who had severe cognitive impairments and required assistance for mobility, was first observed with a bedbug in their room on October 17, 2024. Despite the presence of bedbugs, the initial treatment for Resident #5's room was not administered until October 21, 2024, after a delay in signing the pest control proposal. The resident subsequently developed scratches on their face and groin, indicating potential bedbug bites. Another resident, Resident #2, also experienced issues related to the bedbug infestation. This resident, who had severe cognitive impairment and used a wheelchair, developed multiple blisters and bumps on their back, which were itchy. The resident's room was not treated until November 5, 2024, despite the presence of bedbug bites being noted by the ARNP on October 21, 2024. The delay in treatment led to the resident experiencing ongoing itching and new bites on their arms and face. The facility's pest control policy, as outlined in their 2020 guidelines, was not effectively implemented. The policy required timely inspection and treatment of affected areas, which was not adhered to in this case. The facility's Director of Nursing acknowledged the delay in treatment and the need for more timely pest control measures. The pest control service, Plunkett's, confirmed that proposals for treatment were sent but not promptly signed by the facility, leading to delays in addressing the infestation.
Failure to Update Care Plan After Resident Elopement Attempt
Penalty
Summary
The facility failed to update the Care Plan for a resident who attempted to leave the facility without staff supervision. The resident, who was assessed with a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment, had diagnoses of vascular dementia and psychoactive substance abuse. Despite being independent with ambulation, the resident was noted to have intermittent confusion and a desire to go home, as documented in an Elopement Risk Assessment. On a specific date, the resident left the facility unaccompanied, triggering a door alarm. Staff intervened and provided education to the resident about the need for staff accompaniment when going outside. The Director of Nursing (DON) acknowledged during an interview that the Care Plan should have been updated promptly following such an incident. However, the Care Plan was not updated until the time of the interview, indicating a delay in addressing the resident's elopement risk. The resident's statement revealed that the reason for leaving was to find an ATM to withdraw cash for purchasing a cigar, and he forgot to inform the nurse before exiting. This oversight in updating the Care Plan represents a deficiency in the facility's response to the resident's elopement risk.
Improper Catheter Insertion Leads to Hospitalization
Penalty
Summary
The facility staff failed to properly insert a catheter for a resident, leading to hospitalization. The resident, who had a history of Parkinson's Disease, End Stage Renal Disease, Benign Prostatic Hyperplasia, Bladder Neck Obstruction, Urinary Tract Infection, and Diabetes Mellitus, required maximum assistance with activities of daily living and had a catheter. On the day of the incident, a registered nurse, Staff B, attempted to change the resident's catheter but encountered resistance during insertion. Despite using sterile technique, the resident experienced significant pain, grimacing, and sweating, indicating improper placement. Staff B, with the assistance of a certified nursing assistant, Staff D, and later a licensed practical nurse, Staff C, attempted to adjust the catheter. However, the catheter was not properly placed, as evidenced by the excessive length protruding from the resident's penis and the lack of urine return. Staff B inflated the balloon, causing the resident to bleed profusely from the penis, and the resident continued to express severe pain. Despite the obvious signs of improper placement, Staff B sought multiple opinions before deciding to remove the catheter, which resulted in a significant amount of bright red blood loss. The resident was transferred to the hospital due to excessive bleeding and pain. The hospital's emergency department noted acute gross hematuria and concerns about potential clot formation. A urology consultation confirmed that the catheter had likely been inflated at the prostate, causing trauma. The resident required extensive bladder irrigation and additional interventions to manage the bleeding. Interviews with staff and family members revealed that this was not the first incident involving Staff B and catheter changes, as a similar event had occurred previously, also resulting in physician intervention.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the prep area's stand-up fridge, two long squeezable tubes of whipped topping were found open and undated, contrary to the facility's policy requiring them to be stored in a zip lock bag, labeled, and dated. Additionally, icing and barbeque sauce in squeeze bottles were not labeled or dated. In the walk-in cooler, five cheesecake bites in a Styrofoam container were not labeled or dated, and the Dietary Manager indicated they likely belonged to a staff member. An open bag of basil leaves was also found undated. In the walk-in freezer, an open bag of hash browns and an opened bag of frozen green beans were not dated. Furthermore, in the dry storage area, an open and unsealed bag of egg noodles was found undated. The Dietary Manager confirmed these observations, which were inconsistent with the facility's updated Labeling and Dating Policy that requires ready-to-eat and potentially hazardous foods to be labeled with the product name and the date they were opened, prepared, or when they must be used or discarded.
Failure to Administer Parkinson's Medication on Schedule
Penalty
Summary
The facility failed to adhere to physician's orders for a resident's medication administration, specifically Carbidopa-Levodopa, which is used to manage Parkinson's disease. The Medication Administration Record (MAR) for the resident indicated that the medication should be administered five times a day at specific times: 2 a.m., 6 a.m., 10 a.m., 2 p.m., and 6 p.m. However, a review of the Medication Administration Audit Report revealed that on one occasion, the 2 p.m. dose was administered late at 4:51 p.m., and the subsequent 6 p.m. dose was given at 5:31 p.m., resulting in a very short interval between doses. This deviation from the prescribed schedule was contrary to the facility's Medication Administration Policy, which emphasizes the importance of timely drug therapy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 157 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terrace Glen Village | 1.3 mi | ★★★★★ | 5 | 0 |
| Northbrook Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 24 | 0 |
| Winslow House Care Center | 2.6 mi | ★★★★★ | 10 | 0 |
| Oakview Nursing & Rehablitation - Marion | 2.6 mi | ★★★★★ | 5 | 0 |
| Hiawatha Care Center | 3 mi | ★★★★★ | 7 | 0 |
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