Inspection Reports for
HallMar Village

The investigation was complaint-driven based on reports from residents, family members, and staff regarding prolonged call light response times, residents being left on bedpans too long, and improper medication administration including giving medication to a family member.

The facility failed to ensure dignified care for a resident left on a bedpan for hours with call light out of reach, failed to provide sufficient nursing staff to meet resident needs timely, and failed to properly store and label medications and ensure safe medication administration.

The facility was found deficient in multiple areas including resident dignity and care, range of motion services, nursing staff sufficiency, medication storage and administration, dietary services, and food safety practices. Several residents experienced neglect in care and safety protocols were not consistently followed.

The survey included investigation of complaints #2596361-C, #2601838-C, and #2624432-C, all of which resulted in deficiencies.

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.

The investigation was triggered by complaints and incidents involving Resident #101 and Resident #102 who experienced falls and injuries during mechanical lift transfers. Resident #101 sustained bilateral femur fractures after a fall from a sit-to-stand lift. Resident #102 experienced falls due to improper transfer techniques, including being lifted without mechanical lifts as required. Staff failed to follow care plans and proper transfer protocols. Substantiation status is not explicitly stated but findings confirm deficiencies and harm.

The facility failed to use safe transfer techniques with mechanical lifts for two residents, resulting in one resident sustaining bilateral femur fractures. Staff lacked proper training on mechanical lift use, and modifications to lifts were not properly documented or approved. There were failures in communication and adherence to care plans regarding resident transfer status and safety protocols.

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.

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.

The complaint investigation substantiated concerns of rough and disrespectful care by Staff G, including improper use of lifts and verbal altercations. The facility placed Staff G on administrative leave and terminated employment. Infection control failures were also documented.

The facility failed to ensure residents were treated with dignity and respect, with multiple residents reporting rough and inappropriate care by staff. Additionally, the facility failed to follow enhanced barrier precautions for infection prevention during wound and catheter care for several residents.

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.

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.

The facility failed to consistently treat residents with dignity and respect, provide timely bathing assistance, ensure adequate nursing supervision leading to a resident fall with injury, and maintain accurate medical records including proper medication order transcription. Several residents reported unmet care needs and staff misconduct.

Complaints #125548-C was not substantiated. Complaints #125698-C, #125749-C, #125992-C, and #125996-C were substantiated.

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.

The facility failed to ensure effective supervision to prevent residents from leaving units without staff knowledge and failed to maintain an effective pest control program, resulting in bedbug infestations affecting multiple residents.

Complaints #124224-C, #124725-C, and #125020-C were substantiated.

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.

The facility failed to update the care plan for one resident who attempted to leave the facility unsupervised. The care plan was only updated after the incident was identified during the inspection.

Complaint #123680-C was investigated and found to be not substantiated.

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 #120189-C was not substantiated. Complaints #120819-C and #121159-C were substantiated.

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.

The complaint investigation revealed substantiated issues including failure to follow medication orders and improper catheter insertion that resulted in hospitalization of Resident #3.

The facility failed to administer medication timely for one resident and improperly inserted a catheter for another resident, causing trauma and hospitalization. Additionally, the facility failed to store and label food items according to professional standards.

Complaints #113141-C and #114272-C were substantiated. Facility Self-Reported Incidents #113613-I and #114757-I were substantiated.

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.

The facility failed to maintain proper documentation for sanitizer, dish machine, and food temperature logs in the 2nd floor kitchen during multiple dates in November and December 2023. Staff interviews confirmed gaps in log completion and ongoing training efforts.

The facility failed to maintain proper documentation for sanitizer, dish machine, and food temperature logs on multiple dates in November and December 2023. Staff interviews confirmed gaps in log completion and ongoing training efforts.