Based on record review, observations, and interviews, the facility failed to provide a safe environment and protect residents from resident-to-resident abuse, involving nine of ten residents reviewed (#15, #3, #68, #27, #70, #46, #6, #50 and #59) out of 33 sample residents. Record review and staff interviews revealed Resident #68, significantly cognitively impaired and with a history of trauma, was the victim of four incidents of resident-to-resident physical abuse (11/8/25, 11/25/25 (twice) and 12/3/26).The abusive incidents contributed to the resident being physically abused (shoved, pushed, grabbed, and hit in the face and head), and sustaining physical harm (abrasions, facial contusions) and psychosocial harm (fear, anxiety, agitation, distress (crying). …
F600 citations in Colorado
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F600 more often than its own record predicts
3.60 times the share F600 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F600 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 kept free from physical abuse for two (#3 and #8) of seven residents reviewed for abuse out of 13 sample residents.Resident #4 was admitted to the facility on [DATE] with diagnoses of restlessness and agitation, schizoaffective disorders, paranoid schizophrenia and specified anxiety disorders.On 6/16/26, the staff witnessed Resident #4 hit Resident #8 in the back of the head with a rock, resulting in bruising to the head and a hospital evaluation for Resident #8. The facility determined the altercation was prompted by an earlier visitation from Resident #4's representative. …
Based on record review and interviews, the facility failed to ensure one (#86) of four residents was free from abuse out of 47 sample residents.Specifically, the facility failed to ensure Resident #86 was free from sexual abuse from Resident #54. Findings include: I. Facility policy and procedure The Abuse Prevention policy, revised 4/1/26, was provided by the nursing home administrator (NHA) on 8/25/26 at 12:04 p.m. It read in pertinent part, This facility will establish policies and protocols for preventing sexual abuse, such as identifying when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 3.73% | 2.10× |
| 2024 | 4.56% | 1.94× |
| 2025 | 9.42% | 3.60× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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