Cycle 1
Health 2025-10-02 · Fire 2025-10-02
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cedar Rapids, IA
Hallmar Village
2-star overall rating with 2-star inspections with $11,960 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
8900 C Avenue NE, Cedar Rapids, IA
(319) 369-4638
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
2024-01-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.35
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.70
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.35
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
5.60
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 86.67% |
95.27%
8.6 pts worse
|
Numerator 26 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 51.85% |
53.69%
1.8 pts worse
|
Numerator 14 · Denominator 27 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 12 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 2 · Denominator 40 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 59.26% |
56.45%
2.8 pts better
|
Numerator 16 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 32% |
25.2%
6.8 pts better
|
Numerator 8 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
94.0%
0.2 pts worse
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 88.1% · Q4 91.1% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.0% |
95.2%
17.2 pts worse
|
95.5%
17.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.7%
1.2 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.3% · Q3 2.4% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.0%
1 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 7.7% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
4.9%
1.3 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 5.4% · Q4 5.4% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
20.6%
2.5 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 21.2% · Q3 24.3% · Q4 31.6% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
19.8%
3.7 pts better
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 21.4% · Q3 16.1% · Q4 12.9% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.1% |
18.5%
3.6 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
18.3%
5.2 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 22.6% · Q3 25.0% · Q4 30.6% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.6% |
1.7%
5.9 pts worse
|
1.0%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.6% · Q3 9.2% · Q4 6.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.6% |
2.5%
5.1 pts worse
|
1.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 5.3% · Q3 11.9% · Q4 2.3% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
26.0%
0.2 pts better
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 30.4% · Q3 16.0% · Q4 34.3% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
4.3%
3.4 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 4.8% · Q3 8.9% · Q4 0.0% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.2% |
84.3%
12.1 pts worse
|
81.7%
9.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.0% · Q2 72.1% · Q3 73.9% · Q4 71.4% · 4Q avg 72.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.7% |
13.1%
9.6 pts worse
|
12.0%
10.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 21.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.9% |
73.3%
11.4 pts worse
|
79.7%
17.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
21.3%
3.8 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 21.9% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2024-09-26
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-12-28 · Fire 2023-12-28
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-10-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-10-02
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-10-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-07
E · Potential for more than minimal harm
2025-10-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-10-10
F · Potential for more than minimal harm
2024-09-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-09-26
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-12-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-01-27
F · Potential for more than minimal harm
2023-12-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-27
F · Potential for more than minimal harm
2023-12-28
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-27
F · Potential for more than minimal harm
2023-12-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-27
F · Potential for more than minimal harm
2023-12-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-27
E · Potential for more than minimal harm
2023-12-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-27
E · Potential for more than minimal harm
2023-12-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-10-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-10-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-10-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-10-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-10-02
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-10-06
G · Actual harm
2025-07-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-04-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-05
G · Actual harm
2025-01-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-29
E · Potential for more than minimal harm
2025-01-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-29
D · Potential for more than minimal harm
2025-01-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-09-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-09-27
G · Actual harm
2024-07-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-07-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-02
E · Potential for more than minimal harm
2023-12-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-28
Penalties and ownership
What sits behind the stars
$11,960
2025-07-10
Fine
Fine · fine $11,960
Fine
Ownership
Fletcher, Jonathan
Operational/Managerial Control · Individual
Fletcher, Jonathan
Corporate Director · Individual
Fletcher, Jonathan
Corporate Officer · Individual
Hill-Davis, Nancy
Operational/Managerial Control · Individual
Hill-Davis, Nancy
Corporate Director · Individual
Larson, Duane
Operational/Managerial Control · Individual
Larson, Duane
Corporate Director · Individual
Mercy Medical Center
Operational/Managerial Control · Organization
Meyer, Mark
Operational/Managerial Control · Individual
Meyer, Mark
Corporate Director · Individual
Meyer, Mark
Corporate Officer · Individual
Phs Management, LLC
Operational/Managerial Control · Organization
Presbyterian Homes Housing And Assisted Living, Inc.
Operational/Managerial Control · Organization
Quinn, Timothy
Corporate Director · Individual
Shaffer, Claire
Operational/Managerial Control · Individual
Stephens, Casey
Operational/Managerial Control · Individual
Taeger, Vincent
Operational/Managerial Control · Individual
Umb Bank Na
5% Or Greater Security Interest · Organization
Umb Bank Na
5% Or Greater Mortgage Interest · Organization
Vangenderen, Nathan
Corporate Director · Individual
Vangenderen, Nathan
Corporate Officer · Individual
Nearby options
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5-star overall rating with 4-star inspections with $12,248 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Northbrook Healthcare and Rehabilitation Center
Cedar Rapids, IA
1-star overall rating with 1-star inspections with $38,787 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Winslow House Care Center
Marion, IA
2-star overall rating with 1-star inspections with $43,778 in total fines with 11 recent health deficiencies
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