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
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
0.92
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
5.52
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.08
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.69
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
1.19
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
5.53
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,205
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9903
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.04
Baseline 19.50% · Performance 18.63% · Measure score 6.04 · Achievement 6.04 · Improvement 3.02
Healthcare-associated infections
2.89
Baseline 7.60% · Performance 6.97% · Measure score 2.89 · Achievement 2.89 · Improvement 1.92
Total nurse turnover
2.18
Baseline 34.29% · Performance 54.76% · Measure score 2.18 · Achievement 2.18 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 6.72% · Lower 95% interval 6.52% |
| Discharge to community | 64.26% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 110 · Observed rate 62.73% · Lower 95% interval 54.11% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.06% |
95.27%
0.2 pts worse
|
Numerator 77 · Denominator 81 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 81 |
| Discharge self-care score | 56.67% |
53.69%
3 pts better
|
Numerator 34 · Denominator 60 |
| Discharge mobility score | 21.67% |
50.94%
29.3 pts worse
|
Numerator 13 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 5 · Denominator 80 · Adjusted rate 5.58% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 4.08% |
8.2%
4.1 pts worse
|
Numerator 6 · Denominator 147 |
| Staff flu vaccination coverage | 35.68% |
42%
6.3 pts worse
|
Numerator 81 · Denominator 227 |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 33 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 45 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 2.22% |
25.2%
23 pts worse
|
Numerator 1 · Denominator 45 |
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 · 4Q avg 100.0% |
| 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 · 4Q avg 6.1% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 7.1% |
| 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 · 4Q avg 19.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 25.0% · Used in QM five-star |
| 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 · 4Q avg 8.9% · Used in QM five-star |
| 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 · 4Q avg 2.0% · Used in QM five-star |
| 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 · 4Q avg 23.7% |
| 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 · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 · Adjusted 6.0% · Observed 5.1% · Expected 9.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.5% · Used in QM five-star |
| 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 · 4Q avg 96.3% |
| 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 · Adjusted 19.5% · Observed 15.4% · Expected 18.8% · Used in QM five-star |
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
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#3
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