Cycle 1
Health 2024-02-06 · Fire 2024-02-06
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Denver, CO
Hallmark Nursing Center
3-star overall rating with 3-star inspections with $6,788 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3701 W Radcliff Ave, Denver, CO
(303) 794-6484
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
143
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1986-07-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
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
0.93
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,965
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.55% · Performance 22.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.41% · Performance 8.43% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.21
Baseline 44.30% · Performance 42.39% · Measure score 5.21 · Achievement 5.21 · Improvement 0.48
Adjusted total nurse staffing
2.19
Baseline 3.38 hours · Performance 3.7 hours · Measure score 2.19 · Achievement 2.19 · Improvement 0.81
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 13.75% · Lower 95% interval 8.16% |
| Discharge to community | 40.87% |
50.57%
9.7 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 32.73% · Lower 95% interval 30.31% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 28 · Denominator 44 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 24 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 64 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.43% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 5.07% |
| Staff COVID-19 vaccination coverage | 4.83% |
8.2%
3.4 pts worse
|
Numerator 7 · Denominator 145 |
| Staff flu vaccination coverage | 87.14% |
42%
45.1 pts better
|
Numerator 122 · Denominator 140 |
| Discharge function score | 65.91% |
56.45%
9.5 pts better
|
Numerator 29 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 28% |
25.2%
2.8 pts better
|
Numerator 7 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.3
0.6 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
93.5%
5.9 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.5% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.7%
4.1 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.3% · Q3 2.5% · Q4 4.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.2% |
7.4%
0.8 pts worse
|
11.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.3% · Q3 8.0% · Q4 12.3% · 4Q avg 8.2% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.0%
0.9 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 1.5% · Q3 1.5% · Q4 4.3% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.7% |
11.2%
7.5 pts better
|
19.6%
15.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 0.0% · Q3 1.5% · Q4 5.6% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
20.6%
7.4 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.9% · Q3 17.7% · Q4 11.3% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.1% |
15.2%
5.9 pts worse
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 24.3% · Q3 13.6% · Q4 21.9% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
14.6%
2.1 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 9.5% · Q3 6.2% · Q4 13.4% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.8%
0.4 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.5%
0.1 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.3% · Q3 1.3% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
22.4%
2.5 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 28.8% · Q3 27.5% · Q4 17.8% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
3.7%
2.7 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.3% · Q3 0.0% · Q4 0.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
76.4%
18.9 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 94.7% · Q3 94.7% · Q4 95.6% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
12.8%
1.7 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 14.6% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.1% |
75.6%
8.5 pts worse
|
79.7%
12.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
20.3%
3.1 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 18.8% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-17 · Fire 2022-10-17
13 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2021-06-29 · Fire 2021-06-29
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-31
D · Potential for more than minimal harm
2024-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-05
F · Potential for more than minimal harm
2022-10-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-28
F · Potential for more than minimal harm
2022-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-17
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-17
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-17
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2022-11-30
F · Potential for more than minimal harm
2021-06-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-28
F · Potential for more than minimal harm
2021-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-28
F · Potential for more than minimal harm
2021-06-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-28
D · Potential for more than minimal harm
2021-06-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-09-28
D · Potential for more than minimal harm
2021-06-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-09-28
Inspection history
Recent health citations
G · Actual harm
2024-11-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
E · Potential for more than minimal harm
2023-10-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-04-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-01
G · Actual harm
2022-10-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-15
G · Actual harm
2022-10-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-15
G · Actual harm
2022-10-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-17
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-17
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 2022-11-15
D · Potential for more than minimal harm
2022-10-17
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2022-11-15
E · Potential for more than minimal harm
2021-06-29
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 2021-07-20
E · Potential for more than minimal harm
2021-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-30
D · Potential for more than minimal harm
2021-06-29
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-07-20
Penalties and ownership
What sits behind the stars
$6,788
2024-11-14
Fine
Fine · fine $6,788
Fine
Ownership
Preston, Forrest
5% Or Greater Indirect Ownership Interest · Individual
Pueblo Medical Investors, LLC
5% Or Greater Direct Ownership Interest · Organization
Barnes, Deborah
W-2 Managing Employee · Individual
Cross, Cindy
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Thurmond, Joan
Corporate Officer · Individual
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#3
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