Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

HALLMARK NURSING CENTER

DENVER, CO · 143 certified beds · Last Life Safety survey February 6, 2024

CMS Certification Number 065233 · first certified July 1986

Ownership

Operated by LIFE CARE CENTERS OF AMERICA · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

21
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
13
Inspection & testing records
Of the citations on file

Position within CO

21 citations — more than 63% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (July 2025 to February 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was February 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

This facility21CO median16National median11
Citations on file over three years, compared
MeasureCitations
This facility21
Median facility in CO16
Median facility nationally11

Survey history

Citations at each Life Safety survey
52021-06132022-1032024-02
Citations at each Life Safety survey
Survey dateCitations
June 29, 20215
October 17, 202213
February 6, 20243

Most-cited tags

Most-cited tags at this facility
K-03533K-02112K-03452K-07122K-09232K-03721K-09181K-09141
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32024-02-06
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.22022-10-17
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22022-10-17
K-0712Have simulated fire drills held at unexpected times.22022-10-17
K-0923Have proper medical gas storage and administration areas.22024-02-06
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12022-10-17
K-0918Have generator or other power source capable of supplying service within 10 seconds.12022-10-17
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12022-10-17

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 8
  • Gas, Vacuum, and Electrical Systems Deficiencies 6
  • Miscellaneous Deficiencies 4
  • Egress Deficiencies 2
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies8
Gas, Vacuum, and Electrical Systems Deficiencies6
Miscellaneous Deficiencies4
Egress Deficiencies2
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 6, 2024 — 3 citations

Citations issued on February 6, 2024
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Waiver has been granted (August 31, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (March 5, 2024)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (March 5, 2024)

October 17, 2022 — 13 citations

Citations issued on October 17, 2022
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (November 30, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Waiver has been granted (February 28, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has plan of correction (November 30, 2022)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (November 30, 2022)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (November 30, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (November 30, 2022)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (November 30, 2022)
K-0781Have restrictions on the use of portable space heaters.Deficient, Provider has date of correction (November 30, 2022)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (November 30, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (November 30, 2022)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (November 30, 2022)
K-0925Ensure that sources of ignition are removed from patients receiving respiratory therapy.Deficient, Provider has date of correction (November 30, 2022)
K-0926Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.Deficient, Provider has date of correction (November 30, 2022)

June 29, 2021 — 5 citations

Citations issued on June 29, 2021
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (September 28, 2021)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (September 28, 2021)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 28, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (September 28, 2021)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (September 28, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.