Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Medication carts contained multiple labeling and storage errors, including Lantus and NovoLog pens without open dates, an expired NovoLog pen, and an Ozempic pen stored without its cap and with a needle attached. An RN stated she had administered the Ozempic dose and placed the pen back in the cart while looking for the cap, and another RN was unsure what the date on the NovoLog pen meant. The DON stated that the nurse who opened the insulin or Ozempic pen was responsible for labeling it and that cart drawers should be organized by route.
Infection Control Cleaning Practices Not Followed in Resident Rooms: Housekeeping staff did not follow the facility’s cleaning process in two resident rooms. Observations showed staff cleaning sinks from the bowl upward, using the same rag and mop pad across bathroom and room areas, wiping high-touch items such as call lights and bed remotes with dry rags, and failing to clean several high-touch surfaces including light switches, TV remotes, and door knobs. Housekeeping leadership, the IP, and the DON confirmed that high-touch areas should be disinfected daily and that cleaning should proceed from cleanest to dirtiest.
Call Lights Left Out of Reach for Two Residents: Two residents with significant mobility and cognitive needs did not have their call lights kept within reach while in their rooms. One resident was blind, severely cognitively impaired, and dependent on staff, yet the call lights were found on the bed or headboard instead of at her hip or clipped to the sheet as planned. Another resident with Alzheimer’s disease, parkinsonism, muscle weakness, and repeated falls had the call light placed on a wall hook or near the outlet, where it was blocked by the bed and not reachable from the wheelchair or bed.
Failure to provide consistent restorative therapy: A resident with muscle weakness, gait impairment, and a history of falls was discharged from skilled PT with a restorative bike program to maintain function, but the program was only completed sporadically and then dropped off further. The resident and representative reported the restorative aide was unavailable and services were not consistent, while the PT, unit care coordinator, and DON confirmed staffing shortages and no backup plan for restorative CNA coverage.
A resident reported ants in his room, including ants crawling on him at night, and surveyors observed ants in the room on multiple occasions along with food crumbs on the floor and under furniture. Staff said the room was not treated for ants until during the survey, and records showed prior pest control services focused on other areas of the facility rather than resident rooms.
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.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional standards in two medication carts. During observation of the North medication cart, a Lantus insulin pen was found without an open date, and a second Lantus pen also had no open date. An Ozempic pen was found in the cart drawer without an open date, without its cap on, and with a needle attached while it was being stored. RN #1 stated she had given the Ozempic dose earlier and had placed the pen back in the cart while looking for the cap, and she said the attached needle had not been used. RN #1 also stated she would investigate the unlabeled insulin pen and that insulin pens should have open dates because they are only good for 28 days after opening. During observation of the South medication cart, a Lantus SoloStar pen was found without an open date, and a NovoLog FlexPen had "4/6/26" written on it even though it was 24 days past the pharmacy recommendation date for disposal. RN #2 said she was not sure what the written date meant and acknowledged that if it was the open date, the medication would be expired because it had been more than 30 days since opening. She also stated that open dates are important because some medications are only active for a certain amount of time. In the same cart drawer, an opened bottle of Pro T Gold was stored next to Salonpas patches and an opened box of lancets, with no dividers separating the items. The DON stated that the nurse who opened an insulin or Ozempic pen was responsible for labeling it with the open date. The DON also stated that Ozempic should have the needle removed after administration and the cap replaced before storage, and that a pen stored with a needle attached was probably compromised because the needle was open to air. The DON further stated that medication cart drawers should have medications sorted by route for infection control reasons.
Infection Control Cleaning Practices Not Followed in Resident Rooms
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment on two units. During observations, housekeeping staff did not follow proper cleaning procedures for resident rooms and high-touch surfaces, including door handles, call lights, bed remotes, light switches, television remotes, and bathroom hand rails. Staff also did not consistently clean from cleanest to dirtiest areas, and cleaning practices observed did not match the facility’s stated expectations for disinfecting resident rooms. In one private room, Housekeeper #1 cleaned the bathroom sink, counter, and toilet while wearing the same gloves, then went to the far side of the room and sprayed the window sill and table without changing gloves. She later wiped the sink starting at the bowl and moving up to the handles and faucet, used the same rag on the counter, and wiped the bathroom hand rails with a dry rag. She also wiped the call light and bed remote with a dry rag after sweeping the room, and she used the same mop pad for the room and bathroom. Light switches, the television remote, and room and bathroom door knobs were not cleaned during the observation. In a double occupancy room, Housekeeper #2 cleaned the bathroom sink from the bowl to the faucet, handles, and counter top with the same rag, swept the room from the far end to the bathroom and entry, and mopped the room, bathroom, and entry with the same mop pad. Interviews with housekeeping leadership, the infection preventionist, and the DON confirmed that high-touch items should be cleaned daily with disinfectant, sinks should be cleaned from top down, and separate mop pads should be used for different areas, including the bathroom. The infection preventionist and DON stated that using the same mop pad increases the chances of potential infections.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for mobility and accessibility by not keeping call lights within reach for two residents in their rooms. The deficiency was identified during observations, record review, and staff and resident interviews, and involved Resident #21 and Resident #50, both of whom had care plans that addressed call light access and were identified as at risk for falls. Resident #21 had dementia, a left femoral fracture, severe cognitive impairment, legal blindness, and dependence on staff for most ADLs. The care plan called for two pancake call lights, with one placed at the resident's hip and the other clipped to the sheet. However, during multiple observations the call lights were found on the bed, on the headboard, or three to four feet away from the resident while she was in her wheelchair or bed, and she stated she could not find or use the call light and needed help to toilet. Staff interviews confirmed she was blind, needed assistance to the bathroom, and that the call light should always be available and within reach. Resident #50 had diagnoses including nontraumatic acute subdural hemorrhage, parkinsonism, Alzheimer’s disease, muscle weakness, and repeated falls, with moderate cognitive impairment and substantial to maximal assistance needed for most ADLs. His care plan directed staff to encourage call light use and keep it in reach, but observations showed the call light hanging on a wall hook or on its wire near the outlet while the bed blocked access and the resident sat in his wheelchair nearby. The resident said staff repeatedly placed it out of reach and that he could not call for help from those locations; staff and the DON stated the call light should be on the bed and available for him to reach.
Failure to Provide Consistent Restorative Therapy
Penalty
Summary
The facility failed to provide the appropriate services to maintain a resident’s ability to carry out ADLs when it did not provide nursing restorative therapy as recommended by PT for Resident #6. The resident was admitted with diagnoses including restless legs syndrome, muscle weakness, abnormalities of gait and mobility, and a history of falling. The MDS showed moderate cognitive impairment with a BIMS score of 10 out of 15, and the resident was dependent on staff for toileting, lower body dressing, and transfers. The PT discharge summary recommended that the resident be placed on a nursing restorative therapy program for pedaling on an upper and lower extremity recumbent bike with both feet strapped in for 10 minutes while monitoring oxygen saturations. The care plan included restorative recumbent cross-trainer sessions with set-up assist for 10 minutes on Mondays, Wednesdays, and Saturdays. April documentation showed the program was completed 7 out of 13 opportunities, and a 4/30/26 restorative evaluation stated the resident had been participating without difficulty and that strength was improving. However, the EMR did not contain a May 2026 restorative therapy evaluation. May documentation showed the restorative recumbent cross-trainer program was completed only 2 out of 13 opportunities. The resident and his representative reported that therapy had stopped after discharge from skilled PT and that nursing restorative therapy had not been received consistently because the restorative aide had been out of the building. The unit care coordinator and DON stated there were staffing issues affecting restorative services, including restorative CNAs being out, pulled to the floor, or on leave, and both acknowledged there was no backup plan when restorative CNAs were unavailable. The PT stated the restorative program was intended to prevent decline or maintain gains from therapy and that a resident could decline quicker if the program was not followed consistently.
Pest Control Program Failed to Keep a Resident’s Room Free of Ants
Penalty
Summary
The facility failed to maintain an effective pest control program and did not keep Resident #50’s room free of ants. The resident reported seeing ants in his room several times and said they crawled on him at night while he was in bed. He also said he had complained to staff multiple times, but the ants continued to be present. During survey observations, ants were seen crawling along the baseboard, under the bedside table, and under the resident’s desk, with food crumbs observed on the floor around the bed, around the resident in his wheelchair, and under the desk. No ant traps were observed in the room. Record review showed the facility’s pest control company had treated other areas of the building for cockroaches during prior months, but the documentation did not show treatment of residents’ rooms before the survey. Staff interviews indicated the room was not treated for ants until during the survey. The housekeeping staff and maintenance director both described finding ants and food crumbs in the room, and the maintenance director and NHA stated they had not been alerted to ants in the room until during the survey.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 534 citations issued within 25 miles in the last 12 months — including the 7 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hallmark Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.