Inspection Reports for HallMar Village
8900 C Ave NE, Cedar Rapids, IA 52302, IA, 52302
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 3, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey ending October 2, 2025, related to the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on a credible allegation and plan of correction, resulting in certification effective October 6, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2025
Visit Reason
A complaint investigation for facility reported incident #2649905-I was conducted on October 28-29, 2025.
Findings
The facility was found in substantial compliance with no deficiencies cited.
Complaint Details
Complaint investigation related to incident #2649905-I; facility found in substantial compliance.
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 7
Oct 2, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of complaints and a facility reported incident.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, range of motion and mobility care, sufficient nursing staff, medication labeling and storage, menu adherence and nutritional adequacy, food safety and sanitation, and admission procedures related to veteran benefits eligibility.
Complaint Details
The survey included investigation of complaints #2596361-C, #2601838-C, and #2624432-C, all of which resulted in deficiencies.
Severity Breakdown
SS = D: 4
SS = E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Resident #31 was left on a bedpan for over 3 hours with call light out of reach, violating resident dignity and rights. | SS = D |
| Resident #7 with limited range of motion did not receive appropriate treatment and services to prevent further decrease in mobility. | SS = D |
| Facility failed to provide sufficient nursing staff to ensure resident needs were met timely; call lights were often unanswered for 20 to 45 minutes or longer. | SS = E |
| Insulin was not labeled with date opened and medication carts were left unlocked; medications were improperly given to a family member to administer. | SS = D |
| Resident #4 on NPO diet received a meal tray; pureed diet residents did not receive menu items or approved alternatives. | SS = D |
| Facility failed to discard undated and expired food, did not log food and dishwasher temperatures, and failed to check food temperatures before serving. | SS = E |
| Facility failed to verify eligibility for Veterans benefits for 6 of 10 residents reviewed. | — |
Report Facts
Residents present: 44
Call light wait times: 33
Residents reviewed for veteran benefits: 10
Residents with unverified veteran benefits: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Trained Medication Assistant | Gave medication to family member to administer, violating medication administration policy |
| Staff D | Registered Nurse | Prepared insulin without labeling date opened and left medication cart unlocked |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for medication labeling, call light response, and ROM services |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed expectations for insulin labeling |
| Staff A | Certified Nurses Aide | Reported resident complaints about call light response and dignity issues |
| Staff B | Restorative Aide | Responsible for ROM exercises but had not provided services recently |
| Dietary Manager | Dietary Manager | Confirmed lack of food substitution forms and temperature logs |
| Staff F | Cook | Served minced and moist diet meals without checking food temperatures |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 13, 2025
Visit Reason
A revisit of the survey ending on July 10, 2025 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective July 28, 2025.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jul 10, 2025
Visit Reason
The inspection was conducted as a result of investigations into complaints #128617-C and #129849-C, and a facility reported incident #129195-I occurring from July 8 to July 10, 2025.
Findings
The facility failed to use safe transfer techniques when using a mechanical lift to transfer residents, resulting in injuries including bilateral femur fractures to Resident #101. The facility also failed to provide adequate supervision and accident hazard prevention. Staff lacked proper training on mechanical lift use, and the facility had a 'no lift' policy that was not followed. Multiple interviews and record reviews confirmed unsafe transfer practices and inadequate care planning.
Complaint Details
The visit was complaint-related involving complaints #128617-C and #129849-C, and incident #129195-I. The complaints and incident were substantiated as deficiencies were found related to unsafe transfer practices and resulting resident injuries.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to use safe transfer techniques with mechanical lift resulting in resident injury. | G |
Report Facts
Census: 52
Deficiency count: 1
Survey dates: 2025-07-08 to 2025-07-10
Correction date: Jul 28, 2025
BIIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Identified unsafe transfer practices and was terminated for failure to use full body lift |
| Staff C | Certified Nurse Assistant (CNA) | Assisted in unsafe transfers and was involved in incident with Resident #101 |
| Staff B | Certified Nurse Assistant (CNA) | Assisted in unsafe transfers and witnessed resident distress |
| Staff G | Certified Nurse Assistant (CNA) | Reported concerns about resident knee positioning and transfer techniques |
| Staff K | Certified Medication Aide (CMA) | Involved in resident transfer, lacked mechanical lift training, and denied attending lift training |
| Reported on resident transfer status and staff training issues | ||
| Reported on therapy assessments and transfer evaluations |
Inspection Report
Plan of Correction
Deficiencies: 0
May 7, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified effective May 5, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Apr 28, 2025
Visit Reason
The inspection was conducted related to investigation of facility reported incident #127175-I and complaints #127802-C, #127911-C, and #128230-C completed on 4/28-4/29/2025.
Findings
The facility was found deficient in ensuring residents were treated with respect and dignity, and in infection prevention and control practices. Specific findings included rough and disrespectful treatment of residents by staff, failure to follow enhanced barrier precautions, and inadequate staff education and adherence to infection control policies.
Complaint Details
The investigation was triggered by complaints #127911-C and #128230-C which resulted in deficiencies, while complaint #127802-C resulted in no deficiency. The complaints involved allegations of abuse and neglect by staff member G, including rough handling and verbal mistreatment of residents. The facility terminated Staff G's employment and placed the employee on administrative leave pending investigation.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure 3 of 6 residents reviewed were treated with respect and dignity, including rough handling and verbal mistreatment by staff. |
| Facility failed to follow standard and transmission-based precautions to prevent spread of infections for 3 of 6 residents reviewed, including failure to wear gowns and gloves during wound care and catheter care. |
Report Facts
Resident census: 51
Residents reviewed: 6
Residents not treated with respect: 3
BIMS scores: 15
BIMS score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | C.N.A. | Named in findings related to rough and disrespectful treatment of residents and administrative leave |
| Staff E | Director of Nursing | Involved in investigation and interviews regarding Staff G and resident care |
| Staff F | Registered Nurse | Observed failing to follow enhanced barrier precautions during wound care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 26, 2025
Visit Reason
A complaint investigation for complaint #126360-C, and a revisit of the survey conducted January 16 - 23, 2025 was conducted on February 26 to February 27, 2025.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Complaint Details
Complaint #126360-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 5
Jan 23, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #125548-C, #125698-C, #125749-C, #125992-C, and #125996-C from January 16 through January 23, 2025.
Findings
The facility was found deficient in resident rights, dignity, and respect, as well as in providing consistent bathing and sufficient nursing staff. Specific issues included failure to assist residents appropriately, staff sleeping on duty, and inadequate supervision leading to resident falls and unmet care needs.
Complaint Details
Complaints #125548-C was not substantiated. Complaints #125698-C, #125749-C, #125992-C, and #125996-C were substantiated.
Deficiencies (5)
| Description |
|---|
| Facility failed to treat each resident with dignity and respect, evidenced by staff not assisting Resident #3 as needed and discouraging independence. |
| Facility failed to provide consistent bathing for residents #4 and #7, with documented missed baths and inadequate assistance. |
| Facility terminated employment of staff member found sleeping on duty on 1/5/2025 and provided reeducation to staff on call light policy and fall prevention. |
| Facility failed to provide sufficient nursing staff and supervision, resulting in harm to Resident #3 due to a fall related to unattended walker and delayed response to call lights. |
| Facility failed to maintain complete and accurate medical records for residents #6 and #7, including medication administration and orders. |
Report Facts
Census: 50
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in findings related to sleeping on duty and failure to respond to call lights. |
| Staff B | Certified Nurse Aide | Named in findings related to failure to respond to call lights and assisting resident after fall. |
| Staff D | Licensed Practical Nurse | Named in findings related to failure to supervise residents and failure to report sleeping staff. |
| Staff I | Occupational Therapist | Named in findings related to directing staff not to assist Resident #3. |
| Staff J | Certified Nurse Aide | Named in findings related to failure to assist Resident #3. |
| Staff K | Certified Nurse Aide | Named in findings related to ignoring call lights and discouraging resident assistance requests. |
| Staff F | Certified Nurse Aide | Requested to speak to State Surveyor regarding staffing concerns. |
| Staff E | Registered Nurse | Named in findings related to medication administration errors and job performance issues. |
| Staff G | Scheduler/Medical Records | Named in findings related to medication record keeping and destruction of medication. |
| Staff C | Certified Nurse Aide | Named in findings related to failure to check call lights and resident supervision. |
| Staff D | Licensed Practical Nurse | Named in findings related to failure to supervise residents and failure to report sleeping staff. |
| Staff A | Certified Nurse Aide | Named in findings related to sleeping on duty and failure to respond to call lights. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 14, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective January 10, 2025.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Dec 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to complaints #124224-C, #124725-C, and #125020-C on December 9-10, 2024.
Findings
The facility was found to have deficiencies related to accident hazards and supervision, specifically a resident leaving the unit without staff knowledge and failure to sign out, and failure to maintain an effective pest control program evidenced by bed bug infestations in multiple resident rooms.
Complaint Details
Complaints #124224-C, #124725-C, and #125020-C were substantiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to have an effective process to identify residents who left their units without staff knowledge, including failure of Resident #4 to sign out prior to leaving the unit on two occasions. |
| Facility failed to maintain an effective pest control program to ensure the facility is free of pests and rodents, with documented bed bug infestations in multiple resident rooms. |
Report Facts
Resident census: 41
Dates of resident leaving unit without staff knowledge: 2
Dates of bed bug treatments: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing | Interviewed regarding resident leaving unit and bed bug findings |
| Staff C | Maintenance | Submitted bed bug treatment proposals and coordinated pest control |
| Staff D | ARNP (Nurse Practitioner) | Visited resident and ordered treatment for bed bug bites |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 9, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective September 27, 2024. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 1
Sep 26, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included an investigation of complaint #123680-C.
Findings
The facility failed to ensure that the care plan for one resident who attempted to leave the facility without staff supervision was updated with interventions to prevent future attempts. The complaint was not substantiated.
Complaint Details
Complaint #123680-C was investigated and found to be not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to update the care plan with interventions for a resident who attempted to leave the facility without staff supervision. |
Report Facts
Census: 40
Brief Interview for Mental Status (BIMS) score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unknown (signature illegible) | Campus Admin | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Director of Nursing | Interviewed on 9/26/24 regarding care plan updates |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 8, 2024
Visit Reason
A revisit of the survey ending July 3, 2024 investigating complaints #120189-C, #120819-C, and #121159-C was conducted on August 8, 2024.
Findings
All deficiencies were corrected and the facility was in substantial compliance effective August 2, 2024.
Complaint Details
The visit was a follow-up investigation of complaints #120189-C, #120819-C, and #121159-C.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Jul 3, 2024
Visit Reason
Investigation of complaints #120189-C, #120819-C, and #121159-C conducted from June 28, 2024 through July 3, 2024.
Findings
The facility failed to follow physician orders for 1 of 3 residents, failed to provide appropriate catheter care for 1 of 3 residents resulting in hospitalization, and failed to properly label and date ready-to-eat and potentially hazardous foods.
Complaint Details
Complaint #120189-C was not substantiated. Complaints #120819-C and #121159-C were substantiated.
Deficiencies (3)
| Description |
|---|
| Failed to follow physician orders for medications and treatments for 1 of 3 residents. |
| Failed to ensure appropriate treatment and service with regard to catheter change for 1 of 3 residents, resulting in hospitalization. |
| Failed to label and date ready to eat and/or potentially hazardous foods. |
Report Facts
Resident census: 33
Medication Administration Audit date: Jul 2, 2024
Catheter change date: May 25, 2024
Blood pressure: 117
Blood pressure: 109
Pulse: 116
Blood sugar: 203
Blood loss estimate: 100
Food storage audit frequency: 3
Food storage audit duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Named in catheter change deficiency and provided immediate training and corrective action. |
| Staff D | Certified Nursing Assistant (CNA) | Observed catheter change procedure and assisted with resident care. |
| Staff C | Licensed Practical Nurse (LPN) | Involved in catheter change and assessment of catheter placement. |
| Staff A | Nurse who confirmed catheter change situation and assisted with resident care and hospital transfer. | |
| Dietary Manager (DM) | Reviewed food storage and labeling practices and confirmed deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 28, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective January 28, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 17, 2024
Visit Reason
Investigation of Complaint #118164-C conducted on January 16-17, 2024.
Findings
Complaint #118164 was substantiated without any deficiencies found.
Complaint Details
Complaint #118164 was substantiated without a deficiency.
Inspection Report
Original Licensing
Census: 22
Deficiencies: 2
Dec 28, 2023
Visit Reason
The inspection was conducted as the facility's Initial Certification Survey and investigation of Complaints #113141-C and #114272-C and Facility Self-Reported Incidents #113613-I and #114757-I.
Findings
The facility was found deficient in two main areas: failure to regularly log dish machine, sanitizer, and food temperatures, and failure to ensure resident safety during wheelchair transport, which resulted in a resident fall causing injury and hospitalization.
Complaint Details
Complaints #113141-C and #114272-C were substantiated. Facility Self-Reported Incidents #113613-I and #114757-I were substantiated.
Deficiencies (2)
| Description |
|---|
| Failed to regularly log dish machine, sanitizer, and food temperatures in the kitchen. |
| Failed to ensure resident safety associated with wheelchair transport, resulting in a resident fall with head laceration and femoral fracture. |
Report Facts
Census: 22
Residents reviewed for accidents: 9
Fall incident date: Jul 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Patient Care Technician (PCT) | Pushed Resident #9 in wheelchair and involved in fall incident. |
| Staff D | Registered Nurse (RN) | Responded to Resident #9 fall and provided immediate care. |
| Staff F | Lead Cook | Interviewed regarding kitchen temperature log deficiencies. |
| Staff G | Nutrition and Culinary Director | Confirmed dietary staff completed logs and communicated expectations. |
| Staff A | Clinical Administrator | Confirmed actions in Facility Self-Report and Investigation Report. |
| Staff B | Licensed Practical Nurse (LPN) | Reported on fall incident and staff education. |
| Staff E | Certified Medication Assistant (CMA) | Assisted nurse after fall and reported on staff education. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 11, 2023
Visit Reason
A complaint investigation was conducted for Complaints #106376-C, #108176-C and Facility Self-Reported Incidents #100166-I, #101893-I and #109880-I from March 30, 2023 to April 11, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for Complaints #106376-C, #108176-C and Facility Self-Reported Incidents #100166-I, #101893-I and #109880-I was conducted. The facility was found to be in substantial compliance.
Inspection Report
Routine
Census: 39
Deficiencies: 0
Jun 22, 2020
Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on June 22, 2020.
Findings
The facility was found in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID 19.
Inspection Report
Renewal
Deficiencies: 0
Jan 23, 2020
Visit Reason
The inspection was conducted as a Recertification Survey from January 21 to January 23, 2020, to assess the facility's compliance status.
Findings
The facility was found to be in substantial compliance during the recertification survey.
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