CMS · Colorado Department of Public Health & Environment publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-10-24Record 065427-20251023-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-10-24Record 065427-20251023-F686
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 065427-20251023-F585
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 065427-20251023-F655
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 065427-20251023-F677
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 065427-20251023-F744
F583Keep residents' personal and medical records private and confidential.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-23Record 065427-20240801-F583
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-23Record 065427-20240801-F689
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-23Record 065427-20240801-F697
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-23Record 065427-20240801-F758
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-23Record 065427-20240801-F849
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-23Record 065427-20240801-F947
F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-02-04Record 065427-20220106-F563
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-02-14Record 065427-20220106-F695
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-04Record 065427-20220106-F697
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-04Record 065427-20220106-F744
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-04Record 065427-20220106-F758
F803Ensure 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.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-02-24Record 065427-20220106-F803
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-02-18Record 065427-20220106-F880
F886Perform COVID19 testing on residents and staff.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-02-04Record 065427-20220106-F886