Based on record review and resident interviews, the facility failed to promptly and thoroughly address and attempt to resolve resident complaints and grievances concerning issues of resident care and life in the facility that were important to the residents. The facility failed to ensure residents felt their concerns with call lights, incontinent care, staff treatment and physical plant repairs were addressed and resolved for residents residing in the facility. Due to the facility's failures to answer resident grievances, the residents felt frustrated bringing up the same concerns and not having them addressed. Resident #11 expressed feelings of helplessness and depression over being dependent on staff who were not always responsive to her care needs (see resident interview below). …
F585 citations in Colorado
Grievances · Resident Rights Deficiencies
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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F585 more often than its own record predicts
2.10 times the share F585 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F585.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F585 findings written in Colorado, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#5) of four residents reviewed for grievances out of 23 sample residents.Specifically the facility failed to:- Appropriately respond to a grievance filed on behalf of Resident #5 and offer clear communication and a sufficient description of the events that led to Resident #5's fall with serious injury; and, -Uphold the resident or resident representative's right to obtain a review of the grievance in writing within a reasonable timeframe.Findings include: I. Facility policy and procedureThe Resident and Family Grievances policy, undated, was provided by the nursing home administrator (NHA) on 8/10/26 at approximately 12:00 p.m. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 1.86% | 3.05× |
| 2024 | 0.82% | 1.30× |
| 2025 | 1.35% | 2.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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