Citations in Colorado
Statistics, citations and compliance trends for long-term care facilities in Colorado.
Statistics for Colorado (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Colorado
Failure to Protect Resident from Sexual Abuse: A cognitively intact resident reported that another resident approached her from behind in the dining room, made a sexual comment, and touched her breast. The other resident later admitted the contact. Records showed he had a history of sexually inappropriate comments and wandering into other residents’ rooms, and he had a care plan for sexual inappropriateness with redirection and monitoring interventions.
Housekeeping staff failed to follow infection control practices while cleaning resident rooms. In one room, a housekeeper cleaned the sink and toilet area without hand hygiene or glove changes when moving between dirtier and cleaner areas, did not wait the required dwell time for the toilet disinfectant, and did not clean high-touch items such as light switches, door handles, the call light, or closet handles. In another room, a housekeeper used the same gloves and rag across the sink area, closet door and handles, bed area, bedside table, and resident personal items. Leadership and the IP confirmed that staff should clean from cleaner to dirtier areas, perform hand hygiene and glove changes, and clean high-touch surfaces during room cleaning.
A resident with NASH, hepatic encephalopathy, and CKD developed confusion and disorganized thinking, but the nurse did not complete a timely change-of-condition assessment, obtain transfer-time VS, or notify the NP/MD when EMS was called. The resident’s representative reported worsening AMS and pain, while the hospital later documented severe AMS with elevated ammonia. The facility also held ordered rifaximin because it was pending pharmacy delivery/back order, with no doses given and no documentation that the provider was notified that the antibiotic was unavailable.
A resident with severe dementia and aggressive behaviors struck another resident in the face with a closed fist after the second resident returned to the dining room and tried to take food from the first resident’s plate. Both residents had severe cognitive impairment and histories of physical and verbal aggression, and the victim’s care plan noted food insecurity and the need to offer snacks or an alternate plate when others were eating. Staff separated the residents after the assault, and the victim later could not recall who hit him.
Failure to Supervise a Resident at Risk for Elopement: A resident with dementia, TBI, and chronic respiratory failure had escalating exit-seeking behavior and impaired judgment, yet was able to elope from a secured courtyard gate and later through an office window without staff awareness. After the first elopement, the resident was missing for days before being found by EMS on a highway and was treated for a hip fx, elbow fx, pneumonia, and other medical issues. The record also shows a later elopement after repeated attempts to leave the building.
A facility failed to maintain a safe, clean, and comfortable environment when resident rooms and common areas remained excessively hot for months, with multiple readings in the 80s and residents reporting sweating, discomfort, and poor sleep. Surveyors also found soiled linens, urine odors, stained bedding, dirty toilets, and unclean room conditions, while staff said linens were changed mainly on shower days. In addition, a staff member’s dog was allowed in the building without complete vet records or required parasite/heartworm prevention, and the dog barked at residents and visitors while being informally monitored by staff.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was protected from sexual abuse by another resident. The deficiency involved Resident #60, who was cognitively intact with a BIMS score of 15 and diagnoses including type 2 diabetes, hypertension, and bipolar disorder, and Resident #48, who had moderate cognitive impairment with a BIMS score of 11, used a walker, and had diagnoses including type 2 diabetes, kidney cancer, and hypertension. The facility’s abuse prevention policy required a safe environment and identification, assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or sexual abuse. Resident #60 reported that Resident #48 approached her from behind in the dining room, hugged her, made a sexual comment about her breasts, and touched one of her breasts. She told him to stop and said the behavior was not okay. She later described that he was very close to her and that the incident scared and made her uncomfortable. The nurse assessed Resident #60 and noted no injuries. Resident #48 later admitted to staff that he spoke to Resident #60 and touched her breast, and the facility substantiated the allegation based on interviews and the residents’ statements. Record review showed Resident #48 had a care plan for sexual inappropriateness with interventions such as redirection, reporting inappropriate contact, behavioral health services, and education not to enter female rooms or touch female residents or staff inappropriately. The record also showed he had a history of inappropriate comments toward female staff and wandering into other residents’ rooms or staff-only areas. Despite this, the incident occurred, and later documentation showed he was again observed groping a female resident and making sexually suggestive comments. Interviews with staff indicated Resident #48 was known to wander, make inappropriate comments, and be redirectable, while Resident #60 was alert, oriented, and spent time in common areas such as the dining room and activity room.
Housekeeping Infection Control Failures During Resident Room Cleaning
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment on two units. The deficiency was based on observations, record review, and interviews showing that housekeeping staff did not clean and disinfect resident rooms in a hygienic manner, did not perform hand hygiene while cleaning resident rooms, did not clean high-touch surfaces, and did not follow required dwell times during room cleaning. On one observation, a housekeeper was cleaning a double-occupancy resident room occupied by one resident. The housekeeper used Oxivir 1 to clean the sink and counter, then moved from cleaning the sink area to underneath the sink without completing hand hygiene or changing gloves after moving from a dirtier area to a cleaner area. The housekeeper then used the same dirty gloves to retrieve a clean rag and entered the room with a toilet bowl and urinal disinfectant/cleaner. She sprayed and scrubbed the toilet bowl, rim, and surrounding area, then flushed the toilet without waiting the required 10-minute dwell time. The housekeeper later stated she was finished cleaning the room, but the observation showed that light switches, door handles, the resident call light, and closet handles were not cleaned. On another observation in a different resident room, a housekeeper cleaned the sink and surrounding area, then used the same rag to wipe the resident closet door and handles without completing hand hygiene, changing gloves, or using a clean rag when moving from a dirtier area to a cleaner area. The housekeeper later used the same gloves and rag to clean the headboard of the unoccupied bed, the bottom of the bed, and the surrounding floor, then moved to the occupied side of the room and used the same gloves and rag to wipe the resident bedside table and personal items, including a water container, flowers in a vase, and lotion. Interviews with housekeeping leadership and the infection preventionist confirmed that staff should clean from cleaner to dirtier areas, perform hand hygiene and change gloves when moving from dirtier to cleaner areas, and clean high-touch surfaces such as light switches and door handles during room cleaning.
Delayed assessment and medication start after change in mental status
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with professional standards when the resident experienced a change in mental status and the change was not assessed in a timely manner. The resident had diagnoses including NASH, hepatic encephalopathy, muscle weakness, osteoarthritis, hypertension, ascites, edema, and chronic kidney disease. The resident had been documented as alert and oriented on readmission, but later became confused, disoriented, and had disorganized thinking. The record showed no documentation of a nursing assessment for the change in condition on the day the resident was transferred to the hospital, no vital signs assessment at the time of transfer, and no documentation that the NP or medical director was notified when the resident left for the hospital. The resident’s representative reported that the resident’s confusion began in the morning and worsened through the afternoon, becoming similar to the resident’s prior episode of encephalopathy. The representative said the floor nurse disputed that the resident had a change in mental status and stated the resident was at baseline. The representative ultimately requested EMS, and the resident was transported to the hospital around 6:00 p.m. The hospital later documented altered mental status, inability to follow directions or recall the resident’s own name, and an elevated ammonia level that was considered the likely cause of the altered mental status. The facility also failed to ensure rifaximin, an ordered antibiotic, was started in a timely manner. The medication was ordered for impaired brain function, but the progress note documented it was held because it was pending pharmacy delivery, and the MAR showed all doses were held with none administered before the resident returned to the hospital. The pharmacy later documented the order was rejected because the medication was out of stock or under manufacturer back order. The record did not show that the physician was notified when the medication was unavailable, and staff interviews confirmed confusion about the resident’s baseline status and uncertainty about the medication order and transfer notification.
Resident-to-Resident Physical Abuse During Meal Time
Penalty
Summary
The facility failed to protect one resident from physical abuse by another resident. The cited event involved two residents who lived on a secured unit and both had severe cognitive impairment with behavioral symptoms. One resident had unspecified dementia with agitation, impaired communication, and a history of physical and verbal aggression toward others. The other resident had dementia with psychotic features, hallucinations, delusions, verbal and physical aggression toward other residents, and a history of unpredictable behavior. According to the investigation, after breakfast one resident returned to the dining room and attempted to take food from the other resident’s plate. In response, the first resident stood up and struck the second resident on the left side of the face with a closed fist. Staff then intervened and separated the residents. After the incident, the second resident stated he knew he had been hit but could not recall who hit him or why. The first resident could not be interviewed because his response was illogical even with an interpreter. The record also showed that the second resident had a care plan addressing food insecurity and the need to offer snacks or an alternate plate of food when other residents were eating, because he would reach for other residents’ food when hungry. The incident documentation and skin assessment noted no marks or injury on the second resident’s face after the altercation. The first resident’s record showed ongoing behavioral symptoms, including hitting, kicking, pushing, scratching, grabbing, screaming, cursing, and threatening others, and he was on one-to-one supervision after the altercation.
Failure to Supervise a Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for one resident with dementia, chronic respiratory failure, and traumatic brain injury who had a documented history of exit-seeking behavior and impaired judgment. The resident was admitted with diagnoses including dementia with behavioral disturbance and, beginning in January 2026, began telling staff he wanted to leave the facility. A physician later documented serious concerns about the resident’s safety, poor insight, and impaired judgment, and recommended a wanderguard device. A community assessment on 3/23/26 documented that the resident had poor safety awareness in an unstructured setting, was unsteady while walking without an assistive device, and had a prior history of being struck by a motor vehicle in the community. After the resident was informed that he would no longer be permitted to leave the facility unsupervised, he became angry and increasingly agitated. He argued with staff and threatened to leave against medical advice. Despite the facility being locked and alarmed, the resident went to the secured back patio, was observed by another resident pushing on the gate, and was able to break the gate open and elope without staff knowledge. Staff searched the facility and surrounding area but were unable to locate him. The resident was not found until four days later when the hospital contacted the facility, and he had been found by EMS lying on the side of a highway approximately three miles away from the facility. Following the elopement, the resident was treated for injuries and medical complications including a hip fracture, left elbow fracture, pneumonia, dehydration, generalized weakness, lightheadedness, and COPD exacerbation. The record also shows that on a later occasion the resident again eloped from the facility, this time through a window in an office. Staff were unsure how long he had been missing before he was found sitting outside under a tree. The documentation states that the resident had been exit-seeking and had made several attempts to leave the building that day, and that he opened the window, pushed out the screen, and climbed out without staff awareness.
Unsafe Environment, Poor Linen Sanitation, and Uncontrolled Staff Dog
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable homelike environment for residents by allowing prolonged excessive heat in resident rooms and common areas. Temperatures observed throughout the building repeatedly ranged from the mid-70s to mid-80s Fahrenheit, including hallway and resident room readings of 84 to 85 degrees Fahrenheit on multiple occasions. One resident reported that her room had been hot since the first week of May 2026, that the window air conditioner installed in her room was not sufficient, and that she remained extremely hot and uncomfortable with visible sweating and flushed skin. Another resident said her room reached 85 degrees Fahrenheit overnight, causing sweating and preventing sleep, and she said she wanted staff to change her bed linens and provide a cooling bath, but that did not happen. Staff interviews showed the cooling problems had been ongoing for months and had not been resolved. An LPN said several residents had complained that their rooms were excessively hot since May 2026 and that the cooling system was not adequately cooling certain rooms or common areas. The maintenance director said the swamp cooling system had not been working for some time, that contractors had to replace missing copper piping and damaged electrical wiring, and that even with repairs the system was not sufficient to adequately cool the building. The NHA said formal complaints began in May 2026, that residents were given fans and encouraged to drink fluids, and that the facility was still waiting on quotes and approval for larger cooling changes while temperatures remained uncomfortable. The facility also failed to maintain clean linens and sanitary room conditions in multiple resident rooms. Surveyors observed strong urine odors, wet and soiled bedding, heavily stained sheets and pillowcases, stained toilet seats, and rooms with visible dirt, debris, and body odor. One resident said staff only changed bed linens once a week on shower days, despite wanting them changed more often. Staff interviews indicated sheets were generally changed two times per week on shower days unless visibly soiled, and housekeeping staff described cleaning routines that were not formally tracked. The report also documented that the staff dog visiting the facility was not fully compliant with the facility’s own companion animal policy: the dog had no record of obedience training, was not screened for parasites or heartworms, was not on heartworm preventive treatment, barked at visitors and residents, and was sometimes monitored by other staff while the owner was busy providing care.
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Compliance trends in Colorado
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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