Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hallmark Nursing Center during CMS and state inspections, most recent first.
A resident with Alzheimer's and a history of stroke, requiring two staff members for ADL assistance, was injured when a CNA failed to follow the care plan, resulting in the resident sliding off the bed and sustaining a hip fracture. The CNA, unaware of the care plan requirements, attempted to provide care alone, leading to the incident.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident remained free from accident hazards, resulting in a significant injury. On the day of the incident, a certified nurse aide (CNA) was providing care to the resident and did not adhere to the resident's individualized care plan, which required the assistance of two staff members for bed mobility and incontinent care. As a result, the resident slid off the side of the bed and sustained a left hip fracture, necessitating surgical intervention. The resident involved in the incident had a history of Alzheimer's disease, dementia, hemiplegia/hemiparesis, and a previous stroke, which contributed to her dependency on two staff members for activities of daily living (ADL). The resident's care plan had clearly documented the need for two staff members to assist with turning, repositioning, and incontinence care since December 2020. However, the CNA, who had been caring for the resident for four years, was unaware of these requirements and believed that the care could be provided by one staff member. During the incident, the CNA attempted to provide care alone, which led to the resident sliding off the bed while in a side-lying position. The resident sustained multiple injuries, including a hematoma on the forehead, a laceration on the nose, bruising on the chin, and skin tears on the left lower leg and elbow. The resident was subsequently hospitalized for surgical repair of the hip fracture and returned to the facility after receiving medical treatment.
Removal Plan
- CNA #1 was suspended during the investigation and provided coaching and education on the facility's policy that the resident's care plan must be followed.
- CNA #1 was educated on where to locate a resident's care plan, the care plan interventions, and the expectation to check each resident's care plan before the start of care.
- CNA #1 was educated that any concerns about care were to be brought to the attention of the nurse on duty.
- Resident #1's care plan was revised with appropriate interventions for all care areas.
- All facility nurses and CNAs were educated on the facility's policy for following each resident's care plan, where to find the care plan, and expectations for reporting concerns about care plan interventions.
- All residents were assessed for ADL level of assistance and care needs, and discrepancies were clarified or corrected.
- The facility's quality assurance performance improvement committee developed a plan of improvement.
- A root cause analysis of the incident was conducted.
- Staff education was completed with all nurses and CNAs.
- Each staff member was required to show a return demonstration that they understood and were capable of accessing resident care plans.
- The DON/designee was tasked with ensuring each resident was assessed for appropriate care needs upon admission, quarterly, and with each change in condition, and that the resident's care plan was updated accordingly.
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What surveyors actually found near you
We read the 509 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heights Care & Rehabilitation Llc | 1.6 mi | ★★★★★ | 9 | 0 |
| Littleton Care And Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Lakewood Post Acute And Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Cherrelyn Healthcare Center | 3 mi | ★★★★★ | 1 | 0 |
| Wellsprings Care Center | 3.3 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.