Hallmar Village

In the surveyor’s words

From the most serious findings on record at Hallmar Village, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 10, 2025

  Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to use safe transfer techniques when using a mechanical lift to transfer 2 of 3 (Resident #101 and Resident #102) which resulted in one resident incurring bilateral femur fractures. The facility failed to safely transfer 2 of 2 residents (Resident #101 and Resident #102) from the floor after a fall. The facility reported a census of 52 residents. Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 6/04/25, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. […]

• Actual harm, isolatedF725Jan 23, 2025

  Based on clinical record review, employee record review, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision for residents who occupied a 14 room shift assignment. This resulted in harm to Resident #3 due to her walker being left out of reach when she was put to bed, leading to a fall with injury. Staff failed to perform safety rounds and the resident was not found by staff for a significant amount of time after the fall. Additionally, other residents of the shift assignment were left without call lights in reach and others with call lights going unanswered. The facility reported a census of 50 residents. […]

• Actual harm, isolatedF690Jul 3, 2024

  Based on observation, clinical record review, staff interview, resident interview, and family interview the facility staff failed to properly insert a catheter for 1 of 3 residents reviewed which resulted in hospitalization (Resident #3). The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 3.27.24 indicated Resident #3 had diagnoses that included Parkinson's Disease, End Stage Renal Disease (ESRD), Benign Prostatic Hyperplasia with Lower Urinary Tract symptoms, Bladder Neck Obstruction, Urinary Tract Infection (UTI), and Diabetes Mellitus (DM). […]

• No harm, potential for more than minimal, patternF725Oct 2, 2025

  Based on clinical record review, resident interviews, resident council minutes, call light device reports, staff interviews, and policy review the facility failed to provide sufficient nursing staff to ensure resident needs were met in a timely manner. During the survey residents reviewed for call lights reported waiting for 20 to 45 minutes for call lights to be answered and stated staff turned call lights off without completing cares. The facility reported a census of 44 residents. […]

• No harm, potential for more than minimal, patternF812Oct 2, 2025

  Based on observations, staff interviews, facility documents review, and facility policy review, the facility failed to discard undated and expired food found in 2 of 3 kitchens. The facility food items not contaminated when scoops were left in containers during 2 of 2 main kitchen observations. The facility failed to log food temperatures, refrigerator/freezer temperatures, or dishwasher temperatures to ensure safe food storage, thorough cooking, and sanitation for 3 of 3 kitchen logs observed. The facility additionally failed to check the temperature of mechanically altered diets before serving to residents to ensure safe food holding temperatures during 1 of 2 lunch services observed. The facility reported a census of 44 residents.Findings include: 1. […]