| The Hallmark | |
| 4718 Hallmark Dr, Houston, Texas 77056 | |
| (713) 622-6633 | |
| Name | The Hallmark |
|---|---|
| Location | 4718 Hallmark Dr, Houston, Texas |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 32 |
| Occupancy Rate | 68.44% |
| Medicare ID (CCN) | 676423 |
| Legal Business Name | Brazos Presbyterian Homes Inc |
| Ownership Type | Non Profit - Corporation |
| NPI Number | 1376754028 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Brazos Presbyterian Homes Inc |
| Doing Business As | The Hallmark |
| Address | 4718 Hallmark Dr, Houston, TX 77056 |
| Phone Number | 713-662-6633 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 5.33 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.85 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 1.25 | 0.86 |
| Nurse aide hours per resident per day | 3.23 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 4.56 | 3.42 |
| RN hours per resident per day on the weekend | 0.73 | 0.48 |
| Physical therapist hours per resident per day | 0.21 | 0.07 |
| Total nursing staff turnover | 51.3% | 45.8% |
| Registered nurse turnover | 66.7% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 0 |
| Total Amount of Fines in Dollars | $0 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 0 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Mar 18, 2026 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Apr 10, 2026 |
| Jul 12, 2024 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Jul 31, 2024 |
| Dec 1, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Dec 18, 2023 |
| Dec 1, 2023 | Ensure each resident receives an accurate assessment. F0641, Resident Assessment and Care Planning, Standard inspection | Potential for harm, pattern | Corrected by Dec 20, 2023 |
| Dec 1, 2023 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Dec 4, 2023 |
| Dec 1, 2023 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Dec 29, 2023 |
| Dec 1, 2023 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Dec 22, 2023 |
| Dec 1, 2023 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Dec 22, 2023 |
| Dec 1, 2023 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Dec 20, 2023 |
| Dec 1, 2023 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 22, 2023 |
| Dec 1, 2023 | 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. F0693, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2023 |
| Dec 1, 2023 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2023 |
| Dec 1, 2023 | Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. F0777, Administration, Standard inspection | Potential for harm, isolated | Corrected by Dec 22, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.58 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 5.56 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.93 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.76 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.72 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.78 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | Not Available | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.44 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Not Available | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.34 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 2.3 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 0 | 15.38 |
Afton Oaks Nursing and Rehabilitation Center Location: 7514 Kingsley St, Houston, Texas 77087 Phone: (713) 644-8393 |