Cycle 1
Health 2025-01-16 · Fire 2025-01-16
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Houston, TX
The Hallmark
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
4718 Hallmark Dr, Houston, TX
(713) 963-8525
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-05-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.92
Registered nurse staffing
LPN hours / resident day
1.16
Licensed practical nurse staffing
Aide hours / resident day
3.44
Nurse aide staffing
Weekend hours
4.69
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.3%
2.8 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.1% |
3.3%
3.8 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
18.9%
0.1 pts worse
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
10.8%
10.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
16.1%
8.9 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.9% |
0.5%
8.4 pts worse
|
1.0%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
0.8%
1.2 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
15.0%
8.7 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.2%
3.1 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
89.7%
10 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
12.0%
6 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.3% |
88.0%
8.3 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
25.9%
6.4 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-12 · Fire 2022-08-12
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-08
E · Potential for more than minimal harm
2023-12-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-12
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 2024-07-31
F · Potential for more than minimal harm
2023-12-01
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 2023-12-18
E · Potential for more than minimal harm
2023-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-12-01
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 2023-12-04
E · Potential for more than minimal harm
2023-12-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-12-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-01
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-12-01
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 2023-12-18
D · Potential for more than minimal harm
2023-12-01
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-12-22
F · Potential for more than minimal harm
2022-08-12
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 2022-09-02
E · Potential for more than minimal harm
2022-08-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-12
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 2022-09-02
D · Potential for more than minimal harm
2022-08-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-02
Penalties and ownership
What sits behind the stars
Ownership
Bellows, Warren
Corporate Director · Individual
Braly, Locke
Corporate Officer · Individual
Darden, Sharon
Operational/Managerial Control · Individual
Darden, Sharon
Corporate Director · Individual
Dyar, Robert
Operational/Managerial Control · Individual
Dyar, Robert
Corporate Director · Individual
Elledge, David
Corporate Officer · Individual
Fair, Fairfax
Operational/Managerial Control · Individual
Greene, Marcy
Operational/Managerial Control · Individual
Greene, Marcy
Corporate Director · Individual
Hamilton, Alvina
Operational/Managerial Control · Individual
Hamilton, Alvina
Corporate Director · Individual
Hudson, John
Operational/Managerial Control · Individual
Hudson, John
Corporate Director · Individual
Jo, John
Operational/Managerial Control · Individual
Jo, John
Corporate Director · Individual
Kinsey, Deidre
Operational/Managerial Control · Individual
List, Timothy
Operational/Managerial Control · Individual
Rouchon, Omar
Operational/Managerial Control · Individual
Rouchon, Omar
Corporate Officer · Individual
Tallichet, Henry
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Brookdale Galleria
Houston, TX
1-star overall rating with 2-star inspections with $62,489 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Vosswood Nursing Center
Houston, TX
4-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Woodway Nursing & Rehab
Houston, TX
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $271,160 in total fines with 34 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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