Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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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 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 | — | 5 | 0 |
| Winslow House Care Center | 2.6 mi | — | 10 | 0 |
| Oakview Nursing & Rehablitation - Marion | 2.6 mi | — | 1 | 0 |
| Hiawatha Care Center | 3 mi | — | 7 | 0 |
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