Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#34) of one resident out of 54 sample residents.Resident #34, was admitted on [DATE] with diagnoses that included Alzheimer's disease and dementia with behavioral disturbance. Resident #34 had a history of behavioral symptoms associated with dementia.On 2/9/26 at 4:30 a.m. certified nurse aide (CNA) #13 entered Resident #34's room to assist CNA #2 who was providing incontinence care. Resident #34 was yelling and striking out during care. CNA #2 said CNA #13 placed one hand over Resident #34's mouth and the other hand over the resident's arms while CNA #2 was providing care. CNA #13 said the facility did not pay her enough to get punched. …
F604 citations in Colorado
Restraints · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F604 more often than its own record predicts
1.18 times the share F604 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F604.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F604 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 review and interviews, the facility failed to ensure residents were free from physical restraints for two (#3 and #7) of two residents out of 31 sample residents. Specifically, for Resident #3 and Resident #7, the facility failed to:-Ensure that the resident's representatives were informed of the potential risks and benefits of a wanderguard (a wearable device that helps prevent residents from eloping from the facility);-Ensure the wanderguard was the least restrictive approach for the residents;,-Ensure the residents' wanderguards were monitored for continued use; and,-Develop and implement interventions for reducing the restraint.Findings include:I. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.34% | 0.88× |
| 2024 | 0.60% | 1.63× |
| 2025 | 0.45% | 1.18× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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