Inspection Reports for
Hallmark Nursing Center
3701 W RADCLIFF AVE, DENVER, CO, 80236-
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to a resident falling out of bed and sustaining a hip fracture due to failure to follow the resident's care plan requiring two staff members for bed mobility and incontinent care.
Complaint Details
The complaint investigation found that CNA #1 did not follow Resident #1's care plan requiring two staff members for bed mobility and incontinent care, leading to the resident falling out of bed on 2/27/24 and sustaining a left hip fracture. CNA #1 was unaware of the care plan requirements and was subsequently suspended, educated, and coached. The facility conducted a root cause analysis and implemented corrective actions including staff education and monitoring.
Findings
The facility failed to ensure that Resident #1 received appropriate care per her comprehensive care plan, resulting in a fall from bed and a left hip fracture requiring surgical repair. The deficient practice was corrected prior to the onsite investigation, and corrective actions including staff education and care plan revisions were implemented.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident falling out of bed and sustaining a hip fracture.
Report Facts
Residents assessed for ADL level of assistance: 90
Date of incident: Feb 27, 2024
Date of survey completion: Nov 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in the finding for failure to follow resident's care plan leading to resident fall and injury. |
| Director of Nursing | Director of Nursing (DON) | Interviewed confirming corrective actions and facility substantial compliance. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed with DON regarding the incident and corrective actions. |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 6, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication administration, infection control, and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure safe medication self-administration for Resident #45, incorrect insulin administration for Resident #12, and inadequate infection prevention and control practices including improper cleaning and disinfection procedures.
Deficiencies (3)
Facility failed to ensure Resident #45 did not keep inhaler medications at the bedside without proper assessment and physician order.
Facility failed to ensure Resident #12 was administered the correct dose of insulin according to physician ordered parameters.
Facility failed to maintain an infection control program including inadequate cleaning of residents' rooms, failure to follow manufacturer recommended surface contact times, improper wound care technique, and failure to properly clean and disinfect scissors.
Report Facts
Residents reviewed: 35
Residents affected: 1
Residents affected: 1
Residents affected: 1
Insulin administration errors: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication self-administration assessment and inhaler storage for Resident #45 |
| Director of Nursing | Director of Nursing | Provided facility policies and interviewed regarding medication administration and infection control deficiencies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding insulin administration errors and observed wound care deficiencies |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding insulin administration errors |
| Housekeeper #1 | Housekeeper | Observed and interviewed regarding inadequate cleaning practices |
| Housekeeping Supervisor | Housekeeping Supervisor | Provided cleaning product guidelines and interviewed regarding cleaning procedures |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding insulin administration errors |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Interviewed regarding insulin administration errors |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 5, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety regulations, specifically ensuring that food served to residents is palatable, attractive, and maintained at safe and appropriate temperatures.
Findings
The facility failed to ensure that residents consistently received food at appropriate temperatures, with observations of cold foods served above recommended temperatures and delays causing hot foods to cool before serving. Temperature logs were incomplete, and staff interviews revealed inconsistent temperature monitoring and documentation.
Deficiencies (2)
Failed to ensure resident food was palatable in temperature, with cold foods served above 41°F and hot foods held too long causing temperature drop.
Holding temperature log for the salad bar was not completed for October 2023.
Report Facts
Food temperature: 45.5
Time held in hot box: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Interviewed regarding temperature logs and food temperature monitoring |
| Chef | Chef | Interviewed regarding food temperature checks and documentation |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding facility policy compliance and meal assembly efficiency |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of practice in the nursing facility, specifically focusing on the administration and documentation of wound care treatments for sampled residents.
Findings
The facility failed to ensure that treatments were administered by nursing staff prior to signing the treatment administration record (TAR) and that the nursing staff who administered the treatments signed the TAR. Observations and record reviews revealed discrepancies in treatment dates and signatures for wound care on two residents.
Deficiencies (3)
Treatments were signed out on the TAR before they were actually administered to residents.
Nursing staff who administered treatments did not sign the TAR; instead, other staff signed out treatments they did not perform.
Dressings removed from Resident #2 had no date or nurse initials.
Report Facts
BIMS score: 3
BIMS score: 12
Date of survey completion: Apr 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Signed out treatments on TAR but did not perform dressing changes |
| LPN #1 | Licensed Practical Nurse | Performed dressing changes for Residents #1 and #2 |
| Director of Nursing | Director of Nursing | Provided medication administration audit report and interviewed regarding treatment documentation |
Inspection Report
Routine
Deficiencies: 12
Date: Oct 17, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, grievance resolution, activities of daily living, pressure ulcer care, nutrition, respiratory care, medication management, and hydration.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and respect, timely grievance resolution, adequate activities programming, pressure ulcer prevention and treatment, nutrition and hydration management, respiratory care, medication regimen review, and proper medication labeling and storage.
Deficiencies (12)
Failure to ensure Resident #17 was treated with dignity and respect and cared for in an environment that promoted her quality of life.
Failure to provide prompt efforts to resolve grievances for Residents #76 and #17.
Failure to provide necessary care and services to maintain or improve activities of daily living for Residents #42 and #20, including timely incontinence care and repositioning.
Failure to provide ongoing resident-centered activities program meeting interests and needs for Residents #84 and #71.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Resident #42, including delayed assessment, physician notification, and treatment initiation.
Failure to provide appropriate care to maintain or improve range of motion for Residents #18 and #42, including lack of contracture management and restorative services.
Failure to provide care and services necessary to meet nutritional needs for Resident #36, including inadequate interventions for significant weight loss and failure to address resident complaints about food.
Failure to ensure safe and appropriate respiratory care for Residents #71 and #39, including lack of physician order for oxygen therapy and administration of oxygen at incorrect flow rate.
Failure to ensure Resident #13 was free from unnecessary drugs as pharmacy recommendations to discontinue cetirizine and reduce atorvastatin dosage were not followed.
Failure to ensure all drugs and biologicals were properly labeled with open dates and resident names in medication cart, including eye drops, inhalers, ointments, and insulin.
Failure to follow menus as written, including omission of milk and failure to offer milk substitutes of similar nutritive value on two units.
Failure to ensure residents #58 and #41 had access to sufficient fluids and water pitchers within reach to maintain hydration.
Report Facts
Weight loss: 23.6
Braden scale score: 11
Pressure injury measurement: 2
Pressure injury measurement: 1.7
Pressure injury measurement: 0.2
Oxygen flow rate: 4
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in findings related to Resident #17 grievance and Resident #42 care |
| LPN #4 | Licensed Practical Nurse | Named in findings related to Resident #17 grievance and Resident #42 pressure injury care |
| LPN #5 | Licensed Practical Nurse | Named in findings related to Resident #42 care |
| LPN #6 | Licensed Practical Nurse | Named in findings related to abuse reporting and Resident #20 care |
| CNA #3 | Certified Nurse Aide | Named in grievance handling for Resident #76 |
| CNA #4 | Certified Nurse Aide | Named in findings related to Resident #42 care |
| CNA #5 | Certified Nurse Aide | Named in findings related to Resident #20 and hydration care |
| Director of Nursing | Director of Nursing | Named in multiple interviews related to overall facility compliance |
| Nursing Home Administrator | Nursing Home Administrator | Named in multiple interviews related to grievance and facility compliance |
| Director of Rehabilitation | Director of Rehabilitation | Named in findings related to contracture management |
| Registered Dietitian Consultant | Registered Dietitian Consultant | Named in findings related to nutrition and menu compliance |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in findings related to Resident #36 nutrition |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 29, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident personal funds management, psychotropic medication use, medication storage and labeling, infection prevention and control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to convey resident personal funds within 30 days after discharge or death, failure to ensure gradual dose reductions and appropriate use of psychotropic medications, improper medication storage and labeling, and inadequate infection control practices including improper glove use by housekeeping staff and failure to disinfect dining tables properly.
Deficiencies (7)
Failure to convey personal funds to appropriate individuals within 30 days following resident discharge or death for three residents.
Failure to ensure gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medications for two residents.
Failure to ensure PRN Haldol orders had designated time limits and behavior tracking for appropriate usage.
Medication refrigerator temperatures were consistently above the required range and temperature logs were incomplete.
Medications and biologicals were not properly labeled with resident information and dates opened, including insulin vials and inhalers.
Housekeeping staff failed to follow proper infection control protocols including glove changes and hand hygiene when cleaning resident rooms.
Failure to disinfect dining room tables between residents using appropriate disinfecting wipes; hand sanitizing wipes were incorrectly used for table cleaning.
Report Facts
Remaining personal funds balance: 79
Remaining personal funds balance: 116.14
Remaining personal funds balance: 2129.44
Medication refrigerator temperature: 50
Medication refrigerator temperature: 48
Medication refrigerator temperature: 47
PRN Haldol order duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding resident personal funds accounts and authorization for fund release |
| Nursing Home Administrator | Nursing Home Administrator | Provided facility policies and documentation related to deficiencies and follow-up |
| Social Service Director | Social Service Director | Interviewed regarding psychotropic medication use and behavior tracking |
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic medication use, infection control, and medication storage |
| Housekeeper #1 | Housekeeper | Observed and interviewed regarding cleaning practices and infection control |
| Housekeeper #2 | Housekeeper | Observed and interviewed regarding cleaning practices and infection control |
| Housekeeping Director | Housekeeping Director | Interviewed regarding housekeeping staff training and audits |
| Registered Nurse #5 | Registered Nurse | Interviewed regarding medication storage and labeling |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding medication labeling requirements |
Viewing
Loading inspection reports...
