Based on observations, record review and interviews, the facility failed to ensure that one (#42) of 10 residents reviewed for freedom from involuntary seclusion out of 27 sample residents was provided the least restrictive environment and was not placed on a secured locked unit without an evaluation, assessment, justification, or documentation.Resident #42 was cognitively intact and had no history of wandering. On 7/13/25, following an incident in which she attempted to leave the facility to walk to a nearby store, staff redirected Resident #42 to a room on the secured locked memory care unit. …
F603 citations in Colorado
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F603 more often than its own record predicts
7.44 times the share F603 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F603.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F603 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 observations, record reviews and interviews, the facility failed to ensure that residents were free from involuntary seclusion for two (#85 and #29) of three residents reviewed for proper placement out of 42 of sample residents.Specifically, the facility failed to accurately and timely re-evaluate the appropriateness of Resident #85 and Resident #29's placement in the secure unit.Findings include:I. Facility policy and procedureThe Special Care Unit and Pre-admission Assessment For Initial Placement/Evaluation For Continuing Placement policy was provided by the nursing home administrator (NHA) on 3/12/26 at 4:00 p.m. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2024 | 0.37% | 7.34× |
| 2025 | 0.34% | 7.44× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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